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#2630
E7848_G2000
www.sib.ok.gov or www.healthchoiceok.com
HealthChoice Employer PDP
High and Low Option Plans
With Part D
HealthChoice
High and Low Option Plans
Without Part D
Evidence of Coverage
Plan Year January 1 through December 31, 2012
HealthChoice
Medicare Supplement Plans
Handbook
State Bird, Scissortailed Flycatcher
State Animal, Buffalo State Reptile, Mountain Boomer
Monthly Premiums
HealthChoice Medicare Supplement Plans
January 1, 2012 – December 31, 2012
Medicare Supplement Plan Premiums Per Enrolled Person*
HealthChoice Employer PDP High Option With Part D
$332.54
HealthChoice Employer PDP Low Option With Part D
$273.02
HealthChoice High Option Without Part D
$383.34
HealthChoice Low Option Without Part D
$323.82
COBRA – Medicare Supplement Plan Premiums Per Enrolled Person
HealthChoice Employer PDP High Option With Part D
$332.54
HealthChoice Employer PDP Low Option With Part D
$273.02
HealthChoice High Option Without Part D
$391.01
HealthChoice Low Option Without Part D
$330.30
*The premiums listed above do not reflect contributions from any retirement system. You must pay your full monthly premium (unless you qualify for Extra Help from Medicare) and your Part A , Part B, and/or Part D premiums, if applicable.
Contracting Statement for the Plans With Part D Prescription Drug Coverage
The Oklahoma State and Education Employees Group Insurance Board (OSEEGIB), a division of the Office of State Finance, contracts with the Centers for Medicare and Medicaid Services (CMS), a division of the federal government, to provide Medicare Part D Prescription Drug coverage for its plans with Part D. OSEEGIB is a Medicare approved Part D plan sponsor. Its contract with CMS is renewed annually, and it is not guaranteed beyond the 2012 contract year. OSEEGIB has the right to refuse to renew its contract with CMS or CMS can refuse to renew its contract with OSEEGIB. Termination or non-renewal of the contract will terminate your enrollment in a HealthChoice Employer PDP Medicare Supplement Plan With Part D.
Materials for the Visually Impaired
A text version of this handbook/Evidence of Coverage is available on the HealthChoice website at www.sib.ok.gov or www.healthchoiceok.com. This handbook is also available in CD format at the Oklahoma Library for the Blind and Physically Handicapped (OLBPH). Contact OLBPH, Monday through Friday, 8:00 a.m. to 5:00 p.m. with the exception of state holidays, at:
1-405-521-3514 or toll-free 1-800-523-0288
TDD users call 1-405-521-4672
This publication was printed by the Oklahoma State and Education Employees Group Insurance Board, a division of the Office of State Finance, as authorized by 74 O.S., Section 1301, et seq. 33,500 copies have been printed at a cost of $1.075 each. Copies have been deposited with the Publications Clearinghouse of the Oklahoma Department of Libraries.HealthChoice Medicare Supplement Handbook
Evidence of Coverage
Effective January 1 through December 31, 2012
This HealthChoice handbook/Evidence of Coverage, including the Annual Notice of Change, your enrollment form, Confirmation Statement, and HealthChoice Medicare Formulary, represent our responsibilities to you. This handbook provides details about your health and prescription drug benefits. It explains what is covered and what you pay as a member of the plan. This handbook explains your rights and responsibilities, as well as the rules you must follow to get the services, supplies, and medications you need. This is an important document, so keep it in a safe place. Please note, the HealthChoice Medicare Supplement Plans are often referred to throughout this handbook as the Plan or Plans.
Table of Contents
Plan Identification and Contact Information........................................................................2
Who to Contact About Complaints, Appeals, Grievances, or Coverage Decisions....................3
How Your Plan Will Change for 2012 – Annual Notice of Change ....................................4
Information About Your Premiums......................................................................................6
General Information............................................................................................................10
Summary of HealthChoice High and Low Option Medicare Supplement Plans................14
Pharmacy Benefit Information............................................................................................21
Claim Procedures.............................................................................................................. � 43
Eligibility, Enrollment, and Disenrollment.........................................................................47
Your Responsibilities...........................................................................................................56
Your Rights as a HealthChoice Member..............................................................................57
Grievances and Appeals......................................................................................................62
Fraud, Waste, and Abuse Compliance ................................................................................69
Health Education Lifestyle Planning ..................................................................................70
Notifications.......................................................................................................................71
Plan Definitions...................................................................................................................73Plan Administrator
Oklahoma State and Education Employees Group Insurance Board (OSEEGIB)
A division of the Office of State Finance
Monday through Friday, 7:30 a.m. to 4:30 p.m., Central time
3545 NW 58 Street, Suite 110, Oklahoma City, OK 73112
1-405-717-8701 or toll-free 1-800-543-6044
TDD 1-405-949-2281 or toll-free 1-866-447-0436
HealthChoice Medicare Supplement Plans
Member Services, Monday through Friday, 7:30 a.m. to 4:30 p.m., Central time
With Part D Plans: 1-405-717-8699 or toll-free 1-800-865-5142
Without Part D Plans: 1-405-717-8780 or toll-free 1-800-752-9475
All Members TDD: 1-405-949-2281 or toll-free 1-866-447-0436
Website: www.sib.ok.gov or www.healthchoiceok.com
HealthChoice Health Claims Administrator
HP Administrative Services, LLC, Monday through Friday, 7:30 a.m. to 6:00 p.m., Central time
P.O. Box 24870, Oklahoma City, OK 73124-0870
1-405-416-1800 or toll-free 1-800-782-5218
TDD 1-405-416-1525 or toll-free 1-800-941-2160
HealthChoice Pharmacy Benefit Manager
Medco Customer Service, 24 hours a day/7 days a week
With Part D Plans: Toll-free 1-800-590-6828 or toll-free TDD 1-800-716-3231
Without Part D Plans: Toll-free 1-800-903-8113 or toll-free TDD 1-800-825-1230
Website: www.medco.com
HealthChoice Certification Administrator
APS Healthcare, Monday through Friday, 7:00 a.m. to 7:00 p.m., Central time
P.O. Box 700005, Oklahoma City, OK 73107-0005
Toll-free 1-800-848-8121 or toll-free TDD 1-877-267-6367
Medicare
Customer Service, 24 hours a day/7 days a week
Toll-free 1-800-MEDICARE (1-800-633-4227) or toll-free TTY 1-877-486-2048
Website: www.medicare.gov
Website for Questions and Answers: http://questions.medicare.gov
Social Security Administration
Customer Service, Monday through Friday, 7:00 a.m. to 7:00 p.m., Central time
Toll-free 1-800-772-1213 or toll-free TTY 1-800-325-0778
Website: www.socialsecurity.gov
Plan Identification and Contact Information
2
Calls to HealthChoice received before or after hours, on weekends, or holidays are answered by an automated phone system. Leave a message, including your name and telephone number, and a Member Services Representative will return your call the next business day.3
Plans With Part D
Health Appeals
HP Administrative Services, LLC: Monday through Friday, 7:30 a.m. to 6:00 p.m., Central time
1-405-416-1800 or toll-free 1-800-782-5218
TDD 1-405-416-1525 or toll-free 1-800-941-2160
Pharmacy Coverage Decisions (Prior Authorizations/Exceptions)
Medco, 24 hours a day/7 days a week
Toll-free 1-800-753-2851 or toll-free TDD 1-800-825-1230
Pharmacy Coverage Redeterminations (Appeal Level 1)
HealthChoice Member Services, ask for the Pharmacy Unit
Monday through Friday, 7:30 a.m. to 4:30 p.m., Central time
1-405-717-8699 or toll-free 1-800-865-5142
TDD 1-405-949-2281 or toll-free 1-866-447-0436
Mail or bring your appeal to the HealthChoice Pharmacy Unit at:
OSEEGIB, 3545 NW 58 Street, Suite 110, Oklahoma City, OK 73112
Pharmacy Grievances
HealthChoice Member Services, Monday through Friday, 7:30 a.m. to 4:30 p.m., Central time
1-405-717-8699 or toll-free 1-800-865-5142
TDD 1-405-949-2281 or toll-free 1-866-447-0436
Quality Improvement Organization
Health Integrity, LLC, Monday through Friday, 8:00 a.m. to 7:00 p.m., Eastern time
Toll-free 1-877-772-3379 or toll-free TDD 1-800-855-2880
Email: MEDICinfo@healthintegrity.org
Plans Without Part D
Health Appeals
HP Administrative Services, LLC, Monday through Friday, 7:30 a.m. to 6:00 p.m., Central time
1-405-416-1800 or toll-free 1-800-782-5218
TDD 1-405-416-1525 or toll-free 1-800-941-2160
Pharmacy Appeals
HealthChoice Member Services, ask for the Pharmacy Unit
Monday through Friday, 7:30 a.m. to 4:30 p.m., Central time
1-405-717-8780 or toll-free 1-800-752-9475
TDD 1-405-949-2281 or toll-free 1-866-447-0436
Fax 1-405-717-8925
Mail or bring your appeal to the HealthChoice Pharmacy Unit at:
OSEEGIB, 3545 NW 58 Street, Suite 110, Oklahoma City, OK 73112
Who to Contact About Complaints, Appeals,
Grievances, or Coverage Decisions4
How Your Plan Will Change for 2012
Annual Notice of Change
This Annual Notice of Change provides a summary of the changes in benefits for 2012.
For more specific benefit information, see the Summary of HealthChoice High and Low
Option Medicare Supplement Plans and Pharmacy Benefit Information sections of this
handbook.
Monthly Plan Premiums
Plan Name 2011 2012 Increase
HealthChoice Employer PDP High Option With Part D $308.34 $332.54 $24.20
HealthChoice Employer PDP Low Option With Part D $251.66 $273.02 $21.36
HealthChoice High Option Without Part D $363.06 $383.34 $20.28
HealthChoice Low Option Without Part D $306.38 $323.82 $17.44
Medicare Deductibles
2011 2012 Increase or (Decrease)
Part A ― Hospitalization $1,132.00 $1,156.00 $24.00
Part B ― Medical $ 162.00 $140.00 ($22.00)
Part D ― Prescription Drugs $ 310.00 $320.00 $10.00
HealthChoice Health Benefits
HealthChoice Plans provide supplemental benefits to Medicare Parts A and B. Benefits
are adjusted January 1 of each year to coincide with changes made by Medicare.
HealthChoice Pharmacy Network
The HealthChoice Pharmacy Network includes nearly 60,000 pharmacies across
Oklahoma and throughout the nation. The number of pharmacies in the network equals
or exceeds Medicare’s requirements for pharmacy access in your area. To locate a
HealthChoice Network Pharmacy near you, visit the HealthChoice website at www.sib.
ok.gov or www.healthchoiceok.com or contact Medco, 24 hours a day, 7 days a week at:
With Part D call toll-free 1-800-590-6828 or toll-free TDD 1-800-716-3231
Without Part D call toll-free 1-800-903-8113 or toll-free TDD 1-800-825-1230
Annual Notice of Change
5
Mail Service Pharmacy
Beginning in March 2012, Medicare members who live in Oklahoma will have the option
to purchase their medications through Medco's mail service pharmacy.
Currently, members who live outside Oklahoma already have the option of purchasing
their medications through Medco's mail service pharmacy. Contact Medco at one of the
numbers listed on the previous page for more information about mail service.
HealthChoice Medicare Formulary
There are changes to the HealthChoice Medicare Formulary. Some drugs have been
added to the formulary while other drugs have been removed. Some brand-name drugs
have been replaced with generic drugs. Additionally, some restrictions have been added
to certain drugs.
A comprehensive version of the formulary is available on the HealthChoice website at
www.sib.ok.gov or www.healthchoiceok.com. Click the Member tab in the top menu
and then select Medicare Members, or contact HealthChoice Member Services, Monday
through Friday, 7:30 a.m. to 4:30 p.m., Central time, at:
With Part D call 1-405-717-8699 or toll-free 1-800-865-5142
Without Part D call 1-405-717-8780 or toll-free 1-800-752-9475
TDD users call 1-405-949-2281 or toll-free 1-866-447-0436
HealthChoice Pharmacy Benefits
In accordance with the Centers for Medicare and Medicaid Service's (CMS)
guidelines, the initial coverage limit is increasing from $2,840 to $2,930. See the
Pharmacy Benefit Information section for details.
Certain tobacco cessation products are available for a $0 copay. Additionally,
HealthChoice partners with the Oklahoma Tobacco Settlement Endowment
Trust and Alere Wellbeing to provide members with over-the-counter nicotine
replacement therapy products (patches, gum, and lozenges) and telephone coaching
at no charge. See the Pharmacy Benefit Information section for more information.
For members without Part D, copays for a 30-day fill of specialty medications are
increasing:
yyPreferred medication copays are increasing from $57.50 to $60.00
yyNon-Preferred medication copays are increasing from $115 to $120
Annual Notice of Change
Information About Your Premiums
2012 Medicare Premiums
If you currently pay a premium for Medicare Part A and/or Part B, you must continue to
pay your premiums in order to keep your Medicare coverage. If you do not qualify for
premium-free Part A, you can buy it. The premium for Part A is $451. You must be at
least 65 years old and meet certain other requirements. You can also buy Part A if you are
under age 65 and were once entitled to Medicare because of a disability.
The standard premium for Part B is $99.90. People with higher incomes may pay more.
If you did not sign up for Part B when you first became eligible, your premiums for Part
B may be higher than if you enrolled when you were first eligible. You can delay your
enrollment in Part B if you are still working and have insurance through your employer.
For more information, contact Social Security, Monday through Friday, 7:00 a.m. to 7:00
p.m., Central time, at:
Toll-free 1-800-772-1213 or toll-free TTY/TDD 1-800-325-0778
Paying Your Plan Premiums
You must pay your full monthly premium unless you qualify for Extra Help from
Medicare. Payment of your monthly premium is handled in one of three ways:
Withheld from your retirement check
Withdrawn automatically from your bank account through an automatic draft
Paid directly to OSEEGIB – you will receive a monthly premium statement
COBRA participants must pay premiums directly to OSEEGIB. Your premiums can be
withdrawn automatically from your bank account through an automatic draft, or paid
directly to OSEEGIB – you will receive a monthly premium statement.
Extra Help Paying for Part D Prescription Costs
(Medicare Low Income Subsidy Information)
There is a program available to help people who have limited income and resources as
determined by Social Security. You may be able to get Extra Help paying your monthly
premiums, pharmacy deductibles, and pharmacy copays. This Extra Help also counts
toward your out-of-pocket maximum. If you think you may qualify or want more
information, visit the Social Security website at www.socialsecurity.gov or call Social
6 Information About Your Premiums
Security, Monday through Friday, 7:00 a.m. to 7:00 p.m., Central time, at:
Toll-free 1-800-772-1213 or toll-free TTY/TDD 1-800-325-0778
You can also visit www.medicare.gov, or call Medicare, 24 hours a day, 7 days a week, at:
Toll-free 1-800-MEDICARE (1-800-633-4227)
Toll-free TTY/TDD 1-877-486-2048
After you apply for Extra Help, you will get a letter letting you know whether or not you
qualify and what you need to do next. You may receive full or partial help depending on
your income, family size, and resources.
For the prescription drug portion of your coverage, you pay $0 or a reduced monthly
premium if you qualify for Extra Help. It also helps you pay your prescription drug costs.
If you qualify for Extra Help in 2012, the information below shows the assistance you will
receive for the prescription drug portion of your coverage.
If you qualify for full help, the following benefits apply:
A premium reduction of $31.10
No pharmacy deductible
Continuous coverage (no Coverage Gap)
Maximum copays of $2.60 for generic/Preferred drugs and $6.50 for other drugs
If you qualify for partial help, the following benefits apply:
A premium reduction between $7.80 and $31.10
A pharmacy deductible of $65
Continuous coverage (no Coverage Gap)
Coinsurance of 15% (up to the out-of-pocket maximum)
If you qualify for Extra Help, Medicare notifies HealthChoice and then HealthChoice
notifies you of the amount of Extra Help you will receive.
Note: Extra Help applies to either the High or Low Option Plans with Part D. If you
qualify for Extra Help, HealthChoice will automatically move you to the Low Option Plan
so you pay the lowest premium. If you want to elect the High Option Plan, please notify
HealthChoice in writing at:
HealthChoice
3545 NW 58 Street, Suite 110
Oklahoma City, OK 73112
7
Information About Your Premiums
8
Your request can also be faxed to 1-405-747-8939.
Be aware that if you qualify for Extra Help, some of the information in this handbook/
Evidence of Coverage will not apply to you.
If you qualify for Extra Help and believe you are paying an incorrect copay amount,
HealthChoice will work with CMS to verify your copay level. If it is determined that
your copay is incorrect, the Plan will update its system so that you pay the correct copay.
If you paid a higher copay than you should have, HealthChoice will pay you back.
Note to members who live in a long-term care facility: If the pharmacy hasn’t
collected copays from you and is carrying your copays as a debt you owe, HealthChoice
can make payment directly to the pharmacy.
Your Premium for Part D Could be Higher –
Part D Income-Related Premium Adjustment
As a member of a Medicare supplement plan offered through OSEEGIB, your premium
for Part D prescription drug coverage is included in your monthly premium. If your
income is above a certain level ($85,000 for individuals or $170,000 for married
couples), you must pay an additional premium for your Part D coverage. If you have to
pay an extra amount, the Social Security Administration will send you a letter telling
you the amount. For more information, call Social Security at 1-800-772-1213, Monday
through Friday, 7 a.m. to 7 p.m., Central time. TTY users call toll-free 1-800-325-0778.
If you fail to pay any Part D income-related premium adjustment, HealthChoice must
move you to a plan without Part D.
Changes in Your Monthly Premium
Generally, your premium does not change during the year; however, in certain cases, a
premium change can occur if:
You do not currently get Extra Help but you qualify for it during the plan year,
your monthly premium will decrease.
You currently get Extra Help but the amount of help you qualify for changes, your
premium will be adjusted up or down.
You add or drop dependents to or from your coverage sometime during the plan
year, your premium will increase or decrease.
For more information, see the 2012 Medicare and You handbook, visit www.medicare.
gov, or call Medicare, 24 hours a day, 7 days a week, at the following numbers: Information About Your Premiums
Toll-free 1-800-MEDICARE (1-800-633-4227)
Toll-free TTY/TDD 1-877-486-2048
Late Enrollment Penalty
Medicare applies a late enrollment penalty to your Part D premium when:
You don’t join a Medicare Part D plan, or other plan with creditable prescription
drug coverage, when you first become Medicare eligible at age 65 or when you
become eligible prior to age 65 due to a disability
You have a lapse in creditable prescription drug coverage that lasts longer than 63
continuous days
The late enrollment penalty is applied at the time you enroll in creditable prescription
drug coverage. The penalty is calculated based on the number of months you were
without Creditable Coverage and the amount of the average monthly premium for Part
D plans. The amount of the penalty can change from year to year, and once a penalty is
applied, it will follow you as long as you have Part D prescription drug coverage.
OSEEGIB pays the late enrollment penalty if it applies to a HealthChoice member, but
the penalty could be applied if you leave OSEEGIB and enroll in another insurance plan.
In some cases, you do not have to pay a penalty even though your enrollment is late. The
penalty is not applied if you:
Have creditable prescription drug coverage through another group or government
plan like TRICARE, Veterans Administration, or Indian Health Services
Were without Creditable Coverage for less than 63 days
Receive Extra Help from Medicare
If you become Medicare eligible because of a disability, the late enrollment penalty is
eliminated when you reach your Initial Enrollment Period at age 65 as long as you remain
enrolled in a Part D plan.
If you have questions about the late enrollment penalty, please contact Medicare toll-free
at 1-800-MEDICARE (1-800-633-4227) or toll-free TTY 1-877-486-2048.
Non-Payment of Premiums
If your monthly plan premiums are late, HealthChoice notifies you in writing that you
must pay your premium by a certain date, which includes a grace period, or we will end
your coverage. HealthChoice has a grace period of two months. See When HealthChoice
Must End Your Coverage in the Eligibility, Enrollment, and Disenrollment section.
9
Information About Your Premiums
10
General Information
This Medicare supplement handbook/Evidence of Coverage provides a guide to the
features of the Plans. It is not a complete description of the Plans. Please read this
handbook carefully for information about eligibility rules and benefits. These Plans are
designed to provide supplemental benefits to Medicare Part A and Part B, as well as Part
D prescription drug benefits. Except as noted otherwise in this handbook, services
not covered by Medicare are not covered by the Plans. The Plans' medical benefits
are based on Medicare’s approved amounts. For more information, review your 2012
Medicare & You handbook, visit www.medicare.gov, or call Medicare, 24 hours a day, 7
days a week, at:
Toll-free at 1-800-MEDICARE (1-800-633-4227)
Toll-free TTY 1-877-486-2048
All HealthChoice medical benefits are paid as if you are enrolled in both Medicare Part
A and Part B. If you are not enrolled in Medicare, HealthChoice estimates Medicare’s
benefits and provides coverage as if Medicare were your primary insurance carrier.
For complete information about Medicare enrollment, visit the Social Security
Administration website at www.socialsecurity.gov or contact Social Security customer
service, Monday through Friday, 7:00 a.m. to 7:00 p.m., Central time, at:
Toll-free 1-800-772-1213
Toll-free TTY/TDD 1-800-325-0778
Other websites that can be helpful are the Centers for Medicare and Medicaid Services at
www.cms.gov or Medicare Questions and Answers at http://questions.medicare.gov
The Plans With Part D
The Plans with Part D benefits include Medicare Part D prescription drug coverage.
The Plans Without Part D
The Plans without Part D include pharmacy benefits, but they are not Medicare Part D plans.
These plans are specifically for members who:
Already have Medicare Part D coverage through another plan or employer
Receive a subsidy for prescription drug benefits from their or their spouse’s
employer
Receive Veterans Administration health benefits for prescription drugs
General Information
Note: Premiums for the plans without Part D are higher because HealthChoice does not
receive a subsidy from Medicare for members enrolled in these plans.
Provider-Patient Relationship
Your provider is responsible for the medical advice and treatment they provide, or any
liability resulting from that advice or treatment. Although a provider may recommend or
prescribe a service or supply, this does not of itself establish coverage by the Plans.
Federal Limiting Charge
Providers who do not accept Medicare assignment cannot charge a Medicare beneficiary
more than 115% of Medicare approved amounts. For more information, refer to the section
of your Medicare and You handbook titled Keeping Your Costs Down with Assignment.
Certification
Certification through the HealthChoice certification administrator, APS Healthcare, is
required for inpatient hospital admissions and certain outpatient surgical procedures if
Medicare is not your primary carrier. If you have questions, contact APS Healthcare,
Monday through Friday, 7:00 a.m. to 7:00 p.m., Central time, at:
Toll-free at 1-800-848-8121 or toll-free TDD 1-877-267-6367
The HealthChoice Plans Supplement Medicare Part A
(hospitalization) by:
Paying the inpatient hospitalization deductible and coinsurance in full
Paying for an additional 365 lifetime reserve days for hospitalization
Paying the Part A coinsurance for skilled nurse facility care for days 21 through 100
Paying for the first three pints of blood while hospitalized
The HealthChoice Plans Supplement Medicare Part B (medical) by:
Paying the 20% of medical expenses not paid by Part B*
Paying the 20% of durable medical equipment expenses not paid by Part B*
Paying for some prescription drugs
*You must pay the Part B deductible before Medicare or HealthChoice pays benefits.
11
General Information
12
The HealthChoice Plans Provide Prescription Drug Coverage
2012 Plan Year Low Option Plan High Option
Plan
Pharmacy Deductible $ 320.00 Not Applicable
Cost Sharing/Copay
The next $2,610.00
in prescription costs
You pay 25% or $652.50
Plan pays 75% or $1,957.50
Applicable copay
per prescription
fill
Coverage Gap $3,727.50* Not Applicable
Annual Out-of-Pocket Maximum $4,700.00 $4,700.00
After Annual Out-of-Pocket Maximum 100% 100%
*Members with Part D who reach $2,930 in total drug costs receive certain discounts
when purchasing covered medications. See Medicare Coverage Gap Discount Program
in the Pharmacy Benefit Information Section.
Plan ID Cards
There are two ID cards; one card is for health and dental benefits and the other card is
for pharmacy benefits. If you are currently a HealthChoice member, continue using your
current ID cards. If you are new to HealthChoice, you are issued new ID cards.
Health/Dental ID Card
Please present your HealthChoice health/dental ID card when you receive services. When
you receive health services, you also need to present your red, white, and blue Medicare
card to your provider. Following is an example of your health/dental ID card:
To request replacement health/dental ID cards, contact HP Administrative Services, LLC,
Monday through Friday, 7:30 a.m. to 6:00 p.m., Central time, at:
1-405-416-1800 or toll-free 1-800-782-5218
TDD users call 1-405-416-1525 or toll-free 1-800-941-2160
General Information
Sample
Sample
Prescription Drug ID Card
Please present your HealthChoice prescription drug ID card when you purchase
prescriptions. The pharmacy automatically bills HealthChoice for its share of your
covered prescription drug cost. You do not need to present your Medicare ID card at the
pharmacy. Following is a sample of your prescription drug ID card:
If you don’t have your prescription drug ID card when you fill a prescription, have your
pharmacy contact HealthChoice for your information. If your pharmacy cannot get the
needed information, you may have to pay for your medication and then ask HealthChoice
to pay you back by filing a paper pharmacy claim. See the Claim Procedures section.
To request a replacement prescription drug ID card, visit www.medco.com. You can also
request a replacement card by calling Medco, 24 hours a day, 7 days a week:
With Part D call toll-free 1-800-590-6828 or toll-free TDD 1-800-716-3231
Without Part D call toll-free 1-800-903-8113 or toll-free TDD 1-800-825-1230
Explanation of Benefits (EOB)
Each time a claim is processed, the health claims administrator sends you an EOB which
explains how your benefits are applied. EOBs are also available online by going to the
HealthChoice website at www.sib.ok.gov or www.healthchoiceok.com and clicking
ClaimLink. If you haven’t registered to access ClaimLink, you will need to create a user
name and password to gain access to your information. If you prefer to go paperless and
not receive paper EOBs, contact the health claims administrator. Also, see Pharmacy
Explanation of Benefits (EOB) in the Pharmacy Benefit Information section.
Your Contact Information
It is important to keep your contact information current. You risk delaying claims
processing, missing communications, and even disenrollment from the Plan when your
information is incorrect. Additionally, Medicare requires that you report any changes
in your name, address, or telephone number to your insurance plan. Changes can be
faxed to 1-405-717-8939 or sent in writing to:
HealthChoice, 3545 NW 58 Street, Suite 110, Oklahoma City, OK 73112
13
General Information
Sample
Sample
14
Services
or Items
Medicare
Part A Pays
HealthChoice Pays
You
Pay
Hospitalization:
Semiprivate room, meals, drugs as part of your inpatient treatment, and other hospital services and supplies
First 60 days
All except $1,156, the Part A deductible
$1,156, the Part A deductible
0%
Days 61 through 90
All except $289 per day
$289 per day
0%
Days 91 and after
while using Medicare's 60 lifetime reserve days
All except $578 per day
$578 per day
0%
Once Medicare’s lifetime reserve days are used, HealthChoice provides additional lifetime reserve days Limited to 365 days
0%
100%
of Medicare eligible expenses
Certification by HealthChoice is required
0%
Beyond the additional 365 days
0%
0%
100%
Skilled Nurse Facility Care:
Must meet Medicare requirements, including inpatient hospitalization for at least 3 days and entering a Medicare approved facility within 30 days of leaving the hospital. Limited to 100 days per calendar year
First 20 days
All approved amounts
0%
0%
Days 21 through 100
All except $144.50 per day
$144.50 per day
0%
Days 101 and after
0%
0%
100%
Medicare Part A (Hospitalization) Services
All benefits are based on Medicare Approved Amounts
Summary of HealthChoice High and Low Option
Medicare Supplement Plans Supplemental Benefits for Medicare Part B (Medical)
All Benefits are Based on Medicare Approved Amounts
15
Medicare Part A Continued
Services
or Items
Medicare
Part A Pays
HealthChoice Pays
You
Pay
Hospice Care
Available as long as your doctor certifies you are terminally ill and you elect to receive these services
All but very limited coinsurance for outpatient drugs and inpatient respite care
0%
Balance
Blood
Limited to the first 3 pints unless you or someone else donates blood to replace what you use
0%
100%
0%
Services
or Items
Medicare Part B Pays
HealthChoice Pays
You
Pay
Medical Expenses:
Inpatient and outpatient hospital treatment, such as physician services, medical and surgical services and supplies, physical and speech therapy, and diagnostic tests (Medicare limits apply)
You pay $140, the Part B deductible
0%
0%
$140, the Part B deductible
Remainder of Medicare approved amounts
80%
20%
0%
Part B charges above Medicare approved amounts
0%
100%
0%
Clinical Laboratory Services
Blood tests and urinalysis for diagnostic services
100%
0%
0%
Home Health Care:
Medicare approved services
Medically necessary skilled care services and medical supplies
100%
0%
0%16
Medicare Part B Continued
Services
or Items
Medicare Part B Pays
HealthChoice Pays
You
Pay
Durable Medical Equipment:
Items such as wheelchairs, walkers, and hospital beds
You pay $140, the Part B deductible
0%
0%
$140, the Part B deductible
Remainder of Medicare approved amounts
80%
20%
0%
Blood
Amounts in addition to the coverage under Part A unless you or someone else donates blood to replace what you use
80% after the Part B deductible
20% after the Part B deductible
0%
Hospice
Prescription
Covered for Medicare beneficiaries with a terminal illness
80%
20%
0%
The $140 Medicare Part B deductible is credited towards your HealthChoice deductible upon receipt of Medicare’s Explanation of Benefits (EOB). Once you meet the Part B deductible, your HealthChoice deductible is met for the plan year.
Medicare Part B - Preventive Services
Preventive Services
Who is Covered
Medicare
Part B
Pays
HealthChoice Pays
You
Pay
One-time Initial Wellness Physical Exam:
To be completed within 12 months of your enrollment in Medicare Part B
All Medicare beneficiaries
100%
No Part B deductible
0%
0%Medicare Part B - Preventive Services Continued
17
Preventive Services
Who is Covered
Medicare
Part B
Pays
HealthChoice Pays
You
Pay
Preventive Exam:
Limited to one every 12 months
All Medicare beneficiaries
100%
No Part B deductible
0%
0%
Screening Mammogram:
Limited to one every 12 months
All female Medicare beneficiaries age 40 and older
100%
No Part B deductible
0%
0%
Cardiovascular Screenings:
Limited to one every five years
All Medicare beneficiaries
100%
No Part B deductible
0%
0%
Pap Test and Pelvic Exam:
Limited to one every 24 months; includes a clinical breast exam
Limited to one every 12 months if high risk/abnormal Pap test in preceding 36 months
All female Medicare beneficiaries
100%
No Part B deductible
0%
0%
Diabetes Screening Test:
Limited to two per year
All Medicare beneficiaries at risk of diabetes
100%
No Part B deductible
0%
0%
Diabetes
Self-Management Training
All Medicare beneficiaries with diabetes (insulin and non-insulin users)
80% after the
Part B deductible
20% after the
Part B deductible
0%
Diabetes Monitoring Supplies:
Includes coverage for glucose monitors, test strips, and lancets without regard to the use of insulin
All Medicare beneficiaries with diabetes - must be requested by your doctor
80% after the Part B deductible
20% after the
Part B deductible
0%18
Medicare Part B - Preventive Services Continued
Preventive
Services
Who is
Covered
Medicare
Part B Pays
HealthChoice Pays
You
Pay
Ostomy Supplies: Includes ostomy bags, wafers, and other ostomy supplies
All Medicare beneficiaries in need of ostomy supplies
80% after the Part B deductible
20% after the
Part B deductible
0%
Colorectal Cancer Screening
Fecal Occult Blood Test: Limited to one every 12 months
Flexible
Sigmoidoscopy:
Limited to one every 48 months for age 50 and older; for those not at high risk, 10 years after a previous screening
Colonoscopy:
Limited to one every 24 months if you are at high risk for colon cancer; if not, once every 10 years, but not within 48 months of a screening flexible sigmoidoscopy
Barium Enema: Doctor can substitute for sigmoidoscopy or colonoscopy
All Medicare beneficiaries age 50 and older
100%
No Part B deductible
0%
0%
All Medicare beneficiaries age 50 and older
100%
No Part B deductible
0%
0%
All Medicare beneficiaries; there is no minimum age
100%
No Part B deductible
0%
0%
All Medicare beneficiaries age 50 and older
100%
No Part B deductible
0%
0%
Prostate Cancer Screening
Digital Rectal Exam: Limited to one every 12 months
Prostate Specific Antigen Test (PSA): Limited to one every 12 months
All male Medicare beneficiaries age 50 and older
80% for the digital rectal exam, after the Part B deductible
20% for the digital rectal exam
0%
100%
No Part B deductible
0%
0%19
Services
Who is Covered
Medicare
Part B Pays
HealthChoice Pays
You
Pay
Bone Mass Measurements:
Limited to one every 24 months
All Medicare beneficiaries at risk for losing bone mass
100%
No Part B deductible
0%
0%
Glaucoma Screening: Limited to one every 12 months; must be performed or supervised by an eye doctor who is authorized to do this within the scope of their practice
Medicare beneficiaries
at high risk or having a family history of glaucoma
80% after the Part B deductible
20% after the Part B deductible
0%
Smoking Cessation:
Eight face-to-face visits in a 12-month period
All Medicare beneficiaries
80% after the Part B deductible
20% after the Part B deductible
0%
HIV Screening:
Limited to once every 12 months or up to three times during pregnancy
Pregnant, high risk, or any Medicare beneficiary who requests the test
100% after the Part B deductible
0%
0%
Medicare Part B - Preventive Services Continued
Vaccinations Covered Under Medicare
Some vaccines are covered under Medicare Part B and others are covered under Medicare Part D. What you pay depends on the type of vaccine, where you purchase the vaccine, and who administers the vaccination shot. The rules for coverage of vaccinations can be complicated. If you are not sure how your vaccination is covered, before you go for your vaccination, you may want to contact HealthChoice Member Services, Monday through Friday, 7:30 a.m. to 4:30 p.m., Central time, at:
Members with Part D call 1-405-717-8699 or toll-free 1-800-865-5142
Members without Part D call 1-405-717-8780 or toll-free 1-800-752-9475
TDD users call 1-405-949-2281 or toll-free 1-866-447-043620
Services Covered Only by HealthChoice
Services
Benefits
Medicare
Part B Pays
HealthChoice Pays
You
Pay
Foreign Travel:
Medically necessary emergency care services beginning during the first 60 days of each trip outside the U.S.A.
Contact
Medicare for
foreign travel
exceptions that are covered by Medicare
0%
80% of billed charges after the first $250 of each calendar year
$50,000 lifetime
maximum
First $250 of each calendar year, then 20% and all amounts over the $50,000 lifetime max
No Medicare deductible
Vaccinations Covered Under Medicare Part B
Flu Vaccination:
Limited to one per flu season
Medicare Part B covers the vaccination and administration at 100% if the provider accepts Medicare assignment.
Pneumococcal Vaccination:
One-time vaccination
Medicare Part B covers the vaccination and administration at 100% if the provider accepts Medicare assignment.
Hepatitis B Vaccination:
Limited to beneficiaries at medium to high risk for Hepatitis B
Medicare Part B covers the vaccination and administration at 100% if the provider accepts Medicare assignment.
Shingles Vaccination:
e.g., ZOSTAVAX (zoster vaccine live)
The vaccine and the administration fee are not covered under Part B. See the Pharmacy Benefit Information section for coverage information.
Tetanus Vaccination:
e.g., TETANUS TOXOID
Covered only for those not immunized, following acute injury
Medicare Part B covers the vaccination and administration at 100% if the provider accepts Medicare assignment.21
What You and HealthChoice Pay for Covered
Prescription Drugs Purchased at Network Pharmacies
Medications Purchased at
Network Pharmacies
You
Pay
HealthChoice
Pays
Generic (Tier 1) and Preferred (Tier 2)
medications costing $100 or less
Copay up to $30
per fill
Allowed Charges after
your copay
Generic (Tier 1) and Preferred (Tier 2)
medications costing more than $100
Copay of 25% up
to $60 per fill
Allowed Charges after
your copay
Non-Preferred (Tier 3) medications
costing $100 or less
Copay up to $60
per fill
Allowed Charges after
your copay
Non-Preferred (Tier 3) medications
costing more than $100
Copay of 50% up
to $120 per fill
Allowed Charges after
your copay
Preferred (Tier 5) prescription tobacco
cessation medications
Copay of $0 per fill Allowed Charges
Preferred, high-cost (Tier 4) medications have the same copays as the generic (Tier 1)
and Preferred (Tier 2) medications. Some medications require Prior Authorization.
See Prior Authorization later in this section.
The High Option plans do not have a pharmacy deductible.
Pharmacy benefits may cover up to a 34-day supply or 100 units, whichever is greater.
See Quantity Limits later in this section.
If you take a specialty medication, see Specialty Medications later in this section.
High Option with Part D plan members who reach total drug costs of $2,930 receive
a 50% discount toward their copay costs when purchasing covered brand-name
medications. See Medicare Coverage Gap Discount Program later in this section.
After You Reach the Pharmacy Out-of-Pocket Maximum
After You Pay HealthChoice Pays
$4,700, the pharmacy out-of-pocket
maximum, in prescription drug copays
100% of covered medications for the
remainder of the calendar year once you
reach the $4,700 pharmacy out-of-pocket
maximum
Pharmacy Benefits for HealthChoice
High Option Medicare Supplement Plans
Pharmacy Benefit Information
22
What You and HealthChoice Pay for Covered
Prescription Drugs Purchased at Network Pharmacies
Pharmacy
Deductible
Stage
$320
Initial Coverage
Limit Stage
$2,610
Coverage
Gap Stage
$3,727.50
100%
Benefit
Stage
After $4,700
During the
Deductible
stage, you must
pay the full cost
of your covered
prescription
drugs, up to
$320, before
HealthChoice
begins to pay.
During the Initial
Coverage Limit stage,
you and HealthChoice
share the costs of the
next $2,610 of covered
prescription drugs
purchased at Network
Pharmacies. You pay 25%,
or a total of $652.50, and
HealthChoice pays 75%,
or a total of $1,957.50.
You pay your 25% each
time you fill a covered
prescription drug at a
Network Pharmacy. For
example, if your drug
costs $60, you pay $15.
During the
Coverage Gap
stage, you pay
100% of the
next $3,727.50
of covered
prescription
drugs purchased
at Network
Pharmacies (less
discounts for
members with Part
D) until you reach
the pharmacy
out-of-pocket
maximum of
$4,700.
During
the 100%
Benefit stage,
HealthChoice
pays 100%
of Allowed
Charges
for covered
prescription
drugs
purchased
at Network
Pharmacies for
the rest of the
calendar year.
To reach the 100% Benefit stage, you must pay the following costs:
1. $ 320.00 the Pharmacy Deductible stage
2. $ 652.50 your 25% of costs during the Initial Coverage Limit stage
3. $3,727.50 your costs during the Coverage Gap stage
Low Option with Part D members who reach total drug costs of $2,930 receive a 50%
discount on the cost of covered brand-name medications, and HealthChoice pays 14% of
the cost of generic medications. See Medicare Coverage Gap Discount Program later in
this section.
Pharmacy benefits may cover up to a 34-day supply or 100 units, whichever is greater.
See Quantity Limits later in this section.
For information on the copays for specialty medications, see Specialty Medications later
in this section.
Pharmacy Benefits for HealthChoice
Low Option Medicare Supplement Plans
Pharmacy Benefit Information
Your Prescription Drug Coverage
Basic Rules for Prescription Drug Coverage
HealthChoice generally covers your drugs as long as you follow these basic rules:
You must have a prescription written by your physician or other provider.
You must use a HealthChoice Network Pharmacy.
Your drug must be on the HealthChoice Medicare Formulary (drug list).
Your drug must be prescribed for a medically accepted indication. This means the
drug is either approved by the Food and Drug Administration or accepted as the
standard of good practice within the medical community.
Pharmacy Out-of-Pocket Maximum
All Plans have a pharmacy out-of-pocket maximum of $4,700. This total includes
amounts you spend on deductibles, copays, and coinsurance at Network Pharmacies. If
you are a Low Option Plan member, this total includes amounts you spend during the
Coverage Gap stage. Once you reach the $4,700 out-of-pocket maximum, the Plan pays
100% for covered medications purchased at Network Pharmacies for the remainder of the
calendar year.
Costs That Apply To the Pharmacy Out-of-Pocket Maximum
Medicare has rules about what does and what does not count toward your pharmacy
out-of-pocket maximum. Medications must be covered Part D drugs and listed on the
HealthChoice Medicare Formulary, or covered through one of the exceptions or appeals
processes. Drugs must be purchased at Network Pharmacies for costs to apply to the out-of-
pocket maximum. The following costs count toward your out-of-pocket maximum:
Your deductible, if applicable
Your coinsurance or copays
Your costs during the Coverage Gap stage (Low Option Plans)
Amounts discounted by brand-name drug manufacturers once you reach $2,930 in
total prescription drug costs
Costs That Do Not Apply To the Pharmacy Out-of-Pocket Maximum
Amounts paid by HealthChoice for generic medications once you reach $2,930 in
total prescription drug costs (Low Option Plans with Part D)
23
Pharmacy Benefit Information
24
Costs for medications purchased outside the United States and its territories
Costs for non-covered medications
Costs for medications purchased at non-Network pharmacies when requirements are
not met
Costs for medications covered under Medicare Part A or Part B
Payments made by another group health plan or government health plan such as
TRICARE, the Veterans Administration, or Indian Health Services
Payments for medications made by a third-party with a legal obligation to pay
Pharmacy Coverage Gap Stage (Low Option Plans)
After your total drug costs reach the Initial Coverage Limit stage ($2,930), you pay
the costs of Part D covered drugs (minus discounts) until you reach the out-of-pocket
maximum of $4,700. This period is known as the Coverage Gap stage.
Medicare Coverage Gap Discount Program (With Part D Plans)
Part D plan members who do not receive Extra Help and reach total drug costs of $2,930
are provided discounts on certain Part D drugs purchased at Network Pharmacies.
Prescription drug manufacturers provide discounts on brand-name drugs, and
HealthChoice provides discounts on generic drugs.
The amounts discounted by brand-name manufacturers apply to your pharmacy out-of-pocket
maximum; however, amounts discounted by HealthChoice do not. Discounts are
automatically applied at your pharmacy when you reach $2,930 in drug costs.
Low Option Plans with Part D: After your total drug costs reach $2,930 ($320
deductible plus $2,610 in additional drug costs), brand-name drug manufacturers
provide a 50% discount* toward the cost of covered brand-name medications, and
HealthChoice pays 14% toward the cost of generic drugs.
High Option Plans with Part D: After your total drug costs reach $2,930, brand-name
manufacturers provide a 50% discount* toward your copay amounts for
covered brand-name medications.
*The 50% discount is available only for brand-name drugs whose manufacturers have
agreed to pay it. If a brand-name manufacturer has not agreed to pay the discount,
medications made by that manufacturer are not covered.
HealthChoice Pharmacy Network
In most cases, your prescriptions are covered only if they are filled at a Network
Pharmacy. The HealthChoice Pharmacy Network includes more than 900 pharmacies
Pharmacy Benefit Information
25
across Oklahoma and nearly 60,000 pharmacies nationwide. It also includes a mail service
option. Network Pharmacies contract with our Plans to provide covered prescription drugs
to members. They also provide electronic claim processing, so generally, there are no
paper claims to file.
The HealthChoice Pharmacy Network includes specialized pharmacies such as:
Pharmacies that supply drugs for home infusion therapies.
Pharmacies that supply drugs to residents of long-term care facilities. Usually,
each long-term care facility has its own pharmacy, and residents can get their
prescription drugs through their facility's pharmacy as long as it is in the
HealthChoice Pharmacy Network.
Pharmacies that serve the Indian Health Service/Tribal/Urban Indian Health
Program.
Sometimes a pharmacy leaves the Network. When this occurs, you have to get your
prescriptions filled at another Network Pharmacy. To locate a HealthChoice Network
Pharmacy near you, go to the HealthChoice website at www.sib.ok.gov or www.
healthchoiceok.com. Click Find a Provider in the top menu bar and then select Network
Pharmacies under HealthChoice Provider Listings. You can also contact Medco, 24 hours
a day, 7 days a week, at:
With Part D call toll-free 1-800-590-6828 or toll-free TDD 1-800-716-3231
Without Part D call toll-free 1-800-903-8113 or toll-free TDD 1-800-825-1230
In certain instances, HealthChoice pays for your prescriptions when they are filled at
a non-Network pharmacy; however, a reduced benefit may apply. See Non-Network
Pharmacies later in this section.
Mail Service Pharmacy
Currently, Medicare members who live outside Oklahoma have the option to fill their
prescriptions through Medco's mail service pharmacy; however, effective March 2012,
Medicare members who live in Oklahoma can fill their medications through Medco's mail
service pharmacy. If you would like to fill your prescriptions through the mail service
pharmacy, contact Medco and they will send you the materials you will need to use this
new service. Please contact Medco at:
With Part D call toll-free 1-800-590-6828 or toll-free TDD 1-800-716-3231
Without Part D call toll-free 1-800-903-8113 or toll-free TDD 1-800-825-1230
Pharmacy Benefit Information
The HealthChoice Medicare Formulary
HealthChoice has a list of covered medications, known as the HealthChoice Medicare
Formulary. This list tells which drugs are covered, which drug tier they are in, and if
there are any restrictions that apply.
This formulary was designed with a team of doctors and pharmacists and lists the
categories of drugs believed to be part of a good prescription drug program. Medicare has
approved this formulary. If you were Medicare eligible during the annual Option Period,
a copy of the HealthChoice Medicare Formulary was included in your Option Period
enrollment materials.
The formulary is available on the HealthChoice website at www.sib.ok.gov or www.
healthchoiceok.com. To request a printed copy, contact HealthChoice Member Services,
Monday through Friday, 7:30 a.m. to 4:30 p.m., Central time, at:
With Part D call 1-405-717-8699 or toll-free 1-800-865-5142
Without Part D call 1-405-717-8780 or toll-free 1-800-752-9475
TDD users call 1-405-949-2281 or toll-free 1-866-447-0436
The formulary lists Preferred and non-Preferred drugs. While most generics are
Preferred, some brand-name medications are also Preferred. Generally, HealthChoice
does not cover brand-name drugs when generics are available. Generic drugs have
the same active ingredients as brand-name drugs and are rated by the Food and Drug
Administration (FDA) to be as safe and effective as brand-name drugs. Generics usually
cost less than brand-name drugs. For more information, visit www.sib.ok.gov or www.
healthchoiceok.com or contact Medco, 24 hours a day, 7 days a week, at:
With Part D call toll-free 1-800-590-6828 or toll-free TDD 1-800-716-3231
Without Part D call toll-free 1-800-903-8113 or toll-free TDD 1-800-825-1230
Changes to the Formulary During the Year
Most formulary changes occur at the beginning of each plan year; however, sometimes
formulary changes occur midyear. HealthChoice may:
Add or remove a drug from the formulary
Add or remove a coverage restriction
Replace a brand-name drug with a generic
Move a drug to a higher or lower tier
If a drug you take is affected by a change, HealthChoice is required to notify you at least
60 days before the change, or at the time you request a refill. If you receive notice of
26 Pharmacy Benefit Information
27
a formulary change, work with your physician to switch your prescription to a covered
drug. Depending on the type of change, you may be able to request a prior authorization
and ask HealthChoice to continue to cover the drug for you.
If the Food and Drug Administration finds a drug is unsafe or a drug is removed from the
market, HealthChoice will immediately remove the drug from our formulary and then
notify you of the change. Your doctor will also know about this change and can prescribe
another drug for your condition.
Using the HealthChoice Medicare Formulary
Brand-name and generic medications are listed in the formulary by the general medical
condition they treat and also alphabetically at the back of the formulary. Brand-name
medications appear in all capital letters (LIPITOR) and generic medications are listed
in lower-case italics (atorvastatin). Listed by each drug name is the drug tier and a code
indicating restrictions, if applicable. See Some Drugs Have Restrictions in this section.
Drug Tiers
HealthChoice has a five-tier drug formulary, and in general, each tier represents a different
cost group. Tier 1 medications usually have the lowest out-of-pocket costs, and Tier 3
drugs have the highest out-of-pocket costs. If a generic drug is not available, a Tier 2 drug
is your next least expensive choice. Drug tiers are as follows:
Tier 1 – Generic medications
Tier 2 – Preferred, brand-name medications
Tier 3 – Non-Preferred, brand-name medications
Tier 4 – Preferred, very high cost, and unique formulary drugs
Tier 5 – Preferred tobacco cessation medications with a $0 copay
Medically Necessary Drugs
Your prescription drugs must be deemed reasonable and necessary for the treatment
of your illness or injury. They must also be deemed the accepted treatment for your
condition.
Drugs Covered Under Medicare Part A and Part B
Medicare Part A and Part B provide coverage for some medications. Your HealthChoice
coverage does not affect drugs that are covered under Medicare Part A or Part B.
Pharmacy Benefit Information
28
Medicare Part A covers drugs you receive during Medicare-covered stays in a
hospital or a skilled nursing facility
Medicare Part B covers certain chemotherapy drugs and certain drug injections you
receive in an office visit setting or given at a dialysis facility
Not All Drugs are Covered
Not all prescription drugs are covered. The law does not allow Medicare to cover
certain types of drugs, and HealthChoice decided not to cover certain drugs.
Some Drugs Have Restrictions
Some drugs have additional requirements or coverage limits. If there is a restriction on
a drug you are taking, your provider must take extra steps in order for HealthChoice to
cover your drug.
1. Prior Authorization (PA)
Prior authorization is required before HealthChoice will cover certain drugs, even though
they are listed in the HealthChoice Medicare Formulary. It is required when the drug:
yyHas a very high cost yyMight be covered under Medicare Part B
yyHas specific prescribing guidelines yyIs generally used for cosmetic purposes
See Medications Requiring Prior Authorization (PA) later in this section.
2. Quantity Limits (QL)
Due to approved therapy guidelines, certain drugs have quantity limits. Quantity limits
can apply to the number of refills you are allowed, or how much of the drug you can
receive per fill. Quantity Limits also apply if the medication form is other than a tablet or
capsule. See Medications Subject to Quantity Limits (QL) later in this section.
3. Limited Availability (LA)
Certain drugs are available at only certain pharmacies. For more information, contact
Medco, 24 hours a day, 7 days a week, at:
With Part D call toll-free 1-800-590-6828 or toll-free TDD 1-800-716-3231
Without Part D call toll-free 1-800-903-8113 or toll-free TDD 1-800-825-1230
Pharmacy Benefit Information
29
4. Enhanced Drug (ED)
These drugs are not normally covered, but HealthChoice has elected to cover them. The
amounts you pay for these drugs do not count toward your total drug costs. If you receive
Extra Help paying for your prescriptions, you will not receive help paying for an ED drug.
5. Part B versus Part D Drug (B/D)
These drugs may be covered by Medicare Part B or Part D depending on the situation.
Prior authorization is required to determine how the drug must be billed. Your physician
must provide information about the use and the place the drug is administered.
6. Step Therapy (ST)
Step Therapy requires you to first try a less costly drug to treat your medical condition
before HealthChoice covers another drug for that same condition. For example, drug A and
B both treat the same medical condition. You must first try drug A, and if it does not work
for you, HealthChoice will cover drug B.
Requesting a Pharmacy Prior Authorization
A request for prior authorization must be submitted by your physician. Your request must
be approved before you fill your prescription. To apply:
1. Have your physician’s office contact Medco toll-free at 1-800-753-2851.
2. Medco will fax a Prior Authorization Form to your physician’s office and request
that it be completed and faxed back.
3. If your prior authorization is approved, your physician’s office is notified of the
approval within 24 to 48 hours. You are also notified in writing.
4. If your prior authorization is denied, your physician’s office is notified of denial
within 24 to 48 hours. You are also notified in writing.
Note: In most cases, a prior authorization is valid for one year from the date it is
issued and must be renewed when it expires. For a list of medications that require prior
authorization, see Medications Requiring Prior Authorization (PA) later in this section.
Non-Preferred Prior Authorization (High Option Plans)
If you choose a non-Preferred drug when a Preferred drug is available, you must pay the
non-Preferred copay, unless you get a Tier Exception for a lower copay. Specific medical
guidelines must be met and information must be supplied by your physician to justify your
request. Your physician can contact Medco, 24 hours a day, 7 days a week, at:
Pharmacy Benefit Information
Toll-free 1-800-841-5409 or toll-free TDD 1-800-871-7138
Non-Formulary Medication Prior Authorization
If you are prescribed a medication that is non-formulary, you can:
1. Ask your physician for a prescription for a generic (Tier 1) or Preferred (Tier 2)
medication that is on the HealthChoice Medicare Formulary.
2. Continue the non-covered/non-formulary medication and pay the full cost.
3. Request a prior authorization to receive the medication at the non-Preferred copay.
For more information, contact HealthChoice Member Services, Monday through
Friday, 7:30 a.m. to 4:30 p.m., Central time, at:
With Part D call 1-405-717-8699 or toll-free 1-800-865-5142
Without Part D call 1-405-717-8780 or toll-free 1-800-752-9475
TDD users call 1-405-949-2281 or toll-free 1-866-447-0436
Transition Supply of Medication (Plans with Part D)
A transition supply of medication is a temporary, 34-day supply that is made available to
provide enough time for you to make a transition to a formulary drug or to request a prior
authorization. This one-time supply is available when:
You enroll in a Medicare supplement plan
Your physician writes a new prescription for a drug that is non-formulary
Your newly prescribed medication requires a prior authorization or has quantity
limits
Your medication is no longer covered
You enter or leave a hospital or other setting such as a long-term care facility
Other situations may qualify for a transition supply, and under some circumstances, this
34-day supply can be extended. In rare instances, such as when a medication is excluded
or when a medication is covered under Part B, a transition supply is not available.
For more information on how to obtain a covered transition supply of medication, have
your pharmacy contact Medco at the Pharmacy Help Line 24 hours a day, 7 days a week
including holidays, at:
Toll-free 1-800-922-1557 or toll-free TTY/TDD 1-800-825-1230
30 Pharmacy Benefit Information
Medication Quantities
Pharmacy benefits generally cover up to a 34-day supply or 100 units (tablets or
capsules), whichever is greater. Quantities cannot exceed the FDA approved ‘usual’
dosing recommendations. Some drugs have more restrictive quantity and/or length of
therapy limits. Quantities are subject to your doctor’s written orders.
Specialty Medications
Specialty medications are usually high-cost, injectable medications that require special
handling.
Plans With Part D
You must purchase your specialty medications from a Network pharmacy. Your costs for
Preferred medications are as follows:
yyIf the cost of the medication is $100 or less, you pay up to a $30 copay or the
cost of medication, if less
yyIf the cost of the medication is more than $100 you pay 25% up to a $60
maximum copay
For more information, see the pharmacy benefit charts earlier in this section.
Plans Without Part D
You must purchase your specialty medications from the HealthChoice specialized
pharmacy, Accredo Health. You pay the applicable copay for each 30-day fill. Accredo
provides free supplies, such as needles and syringes, free shipping, refill reminder calls,
and personal counseling with a registered nurse or pharmacist. If you don’t order your
specialty medications through Accredo, you must pay the full cost. Your costs are:
yyPreferred medications – $60 copay for each 30-day supply
yyNon-Preferred medications – $120 copay for each 30-day supply
For more information, contact Accredo:
Toll-free 1-800-501-7260 or toll-free TDD 1-800-759-1089
Tobacco Cessation Products
HealthChoice covers two, 90-day courses of the following tobacco cessation medications
31
Pharmacy Benefit Information
for a $0 copay when they are purchased at a Network Pharmacy:
Buproban 150mg Tabs Nicotrol NS 20mg/m Nasal Spray
Bupropion HCL SR 150mg Tabs Nicotrol 10mg Cartridge
Chantix 0.5mg and 1mg Tabs
Additionally, HealthChoice partners with the Oklahoma Tobacco Settlement Endowment
Trust (TSET) and Alere Wellbeing to provide over-the-counter nicotine replacement
therapy products (patches, gum, and lozenges) and telephone coaching at no charge. To
take advantage of these benefits, contact the Oklahoma Tobacco Helpline at 1-800-QUIT-NOW
(1-800-784-8669) and identify yourself as a HealthChoice member. The Helpline
hours of operation are 7 a.m. to 2 a.m. seven days a week. Members living outside
Oklahoma call 1-866-QUIT-4-LIFE (1-866-784-8454).
Vaccines Covered Under Your Pharmacy Benefits
The rules for coverage of vaccinations are complicated. If you have a question about how
a particular vaccine is covered, contact Medco, 24 hours a day, seven days a week, at:
With Part D call toll-free 1-800-590-6828 or toll-free TDD 1-800-716-3231
Without Part D call toll-free 1-800-903-8113 or toll-free TDD 1-800-825-1230
The coverage of vaccinations includes two parts – the cost of the medication itself and
the cost of giving the vaccination shot. What you pay for a Part D covered vaccination
depends on three things:
1. The type of vaccine – some vaccines are covered under Medicare Part D, while
others are covered under original Medicare
2. Where you get the vaccine medication
3. Who gives you the vaccination shot
Plans With Part D
yyIf the vaccine is purchased through and administered by a pharmacist who
is certified to give vaccines, the pharmacy electronically submits a claim
for the vaccine and the administration fee. You are responsible for the
appropriate copay.
yyIf you purchase the vaccine from your pharmacy and take it to your
physician’s office for administration, your pharmacy electronically submits
a claim for the vaccine medication, but you have to file a paper claim with
Medco for reimbursement of the administration fee.
32 Pharmacy Benefit Information
yyIf you get a Part D vaccine at your doctor's office, you must pay the entire
cost of the vaccine and its administration. You can then file a paper claim
for reimbursement of the vaccine and the administration fee, minus the
appropriate copay.
Plans Without Part D
yyYou are responsible for administration fees for vaccines covered under
pharmacy benefits.
When You are Hospitalized
If you are admitted to a hospital for a Medicare-covered stay, Part A should cover
your prescription drug costs. Once you leave the hospital, HealthChoice covers your
prescription drugs as long as they meet the rules for coverage. HealthChoice also covers
your drugs if they are approved through a coverage determination, exception, or appeal.
When You are Admitted to a Skilled Nursing Facility
If you are admitted to a skilled nursing facility for a Medicare-covered stay, after
Medicare Part A stops paying for your prescriptions, HealthChoice covers them as long as
they meet the rules for coverage. The facility must be a HealthChoice Network Pharmacy,
and the drug cannot be covered under Part B. HealthChoice also covers your drugs if they
are approved through a coverage determination, exception, or appeal.
When You Live in a Long-term Care Facility
Usually, a long-term care facility, such as a nursing home, has its own pharmacy, or a
pharmacy that supplies drugs to its residents. If you reside in a long-term care facility, you
can get your drugs through the facility's pharmacy as long as they are part of the pharmacy
network.
Accessing Part D Medications During a
Declared National Disaster or Public Health Emergency
Members with Part D can replace lost or damaged medications if the loss occurred as the
result of a declared national disaster or public health emergency. Your pharmacy must
contact Medco's Pharmacy Help Line toll-free at 1-800-922-1557. Medco will work with
your pharmacy to authorize early refills or override the maximum days' supply per fill.
You must still pay the applicable copay per fill.
Pharmacy Benefit Information
33
Drug Safety Programs
Medco conducts drug reviews to make sure members receive safe and appropriate
prescription therapies. These reviews can be very important to those who have more
than one provider prescribing medications. Each time you fill a prescription, a review is
conducted to look for possible problems such as:
Medication errors
Dosage errors
Drugs that are not necessary because you take another drug for the same condition
Drugs that may be unsafe or inappropriate because of your age or gender
Combinations of drugs that could harm you if taken at the same time
Drugs you are allergic to
If any possible problems are detected, Medco notifies your pharmacist at the time your
prescription is filled.
Medication Therapy Management (Plans with Part D)
Medication Therapy Management (MTM) is a free program for members who suffer
from multiple, chronic health conditions and are being treated with multiple medications.
To be eligible, you must be expected to incur prescription drug costs that exceed $3,100
annually.
If you qualify, you are automatically enrolled in the program and will receive a letter
from Medco. The letter includes information about the program and a toll-free number
you can call to speak with a Medco pharmacist. Medco’s pharmacists are specially
trained in patient counseling and are prepared to discuss such topics as medication use
and compliance, drug education, health and safety, and cost saving measures. While the
program is voluntary, HealthChoice encourages eligible members to participate.
If you do not wish to participate in the program, you can contact Medco. For more
information, contact Medco, 24 hours a day, 7 days a week, at:
Toll-free 1-800-590-6828 or toll-free TDD 1-800-716-3231
Non-Network Pharmacies
Although HealthChoice may cover your prescriptions when they are purchased at a non-
Network pharmacy, a reduced benefit applies. An exception can be made in the event of
an emergency. It is considered an emergency when you:
Travel outside the HealthChoice service area and run out of medication, or become
34 Pharmacy Benefit Information
ill and need a covered medication and are unable to access a Network Pharmacy
Cannot timely get a covered medication within your plan’s pharmacy network
Fill a prescription for a medication that is not stocked at a Network Pharmacy
Receive a prescription for a covered medication that is dispensed by a non-
Network outpatient facility, such as an emergency room, clinic, or surgery center
If you must use a non-Network pharmacy, you must pay the full cost for your medication
and then ask HealthChoice to repay you for its share of the cost. See the Claim
Procedures section. Before you fill a prescription in this situation, check to see if there is
a Network Pharmacy in your area. See the HealthChoice website at www.sib.ok.gov or
www.healthchoiceok.com. You can also contact Medco, 24 hours a day, 7 days a week
at:
With Part D call toll-free 1-800-590-6828 or toll-free TDD 1-800-716-3231
Without Part D call toll-free 1-800-903-8113 or toll-free TDD 1-800-825-1230
Pharmacy Explanation of Benefits (EOB)
A pharmacy EOB gives the total amount you have spent on your prescription drugs and
the total amount the plan has paid for your prescription drugs. This report is to help you
track your prescription drugs costs. HealthChoice is not required to send you a pharmacy
EOB, but you can request one by calling Medco, 24 hours a day, 7 days a week, at:
With Part D call toll-free 1-800-590-6828 or toll-free TDD 1-800-716-3231
Without Part D call toll-free 1-800-903-8113 or toll-free TDD 1-800-825-1230
Creditable Prescription Drug Coverage
HealthChoice Medicare Supplement Plans With and Without Part D provide Creditable
Coverage. Prescription drug coverage is called creditable if it meets or exceeds
Medicare’s prescription drug coverage guidelines. The HealthChoice Plans provide
coverage equal to (Low Option Plans) or better than (High Option Plans) the standard
benefits set by Medicare. HealthChoice is not required to send you a Creditable Coverage
letter, but if you need one, it is available on the HealthChoice website at www.sib.ok.gov
or www.healthchoiceok.com. Click the Members tab in the top menu bar and then select
Medicare Members. You can also request one by contacting HealthChoice Member
Services, Monday through Friday, 7:30 a.m. to 4:30 p.m., Central time, at:
With Part D call 1-405-717-8699 or toll-free 1-800-865-5142
Without Part D call 1-405-717-8780 or toll-free 1-800-752-9475
TDD users call 1-405-949-2281 or toll-free 1-866-447-0436
35
Pharmacy Benefit Information
What Types of Drugs Are NOT Covered
If you take a drug that is excluded from coverage, you must pay for that drug yourself.
Generally, HealthChoice cannot cover drugs that are:
1. Covered under Medicare Part A or Part B
2. Purchased outside the United States
3. Prescribed for off-label use – this means any use of a drug other than those indicated
on the drug's label
Also, by law, the following drug categories are excluded from coverage:
Most barbiturates and benzodiazepines Fertility drugs
Cough and cold medications Lost, stolen, or damaged medications**
Over-the-counter drugs Drugs not approved by the FDA
Drugs used for the treatment of anorexia,
weight loss, or weight gain
Drugs used for cosmetic purposes or
hair regrowth
Brand-name drugs from manufacturers
that do not participate in the Coverage
Gap Discount Program
All over-the-counter and prescription
vitamins – except prenatal vitamins
Impotency medications such as Cialis,
Levitra, Viagra, and Caverject*
If you receive Extra Help from Medicare to pay for your prescriptions, the Extra Help
program does not pay for drugs that are excluded from coverage. Additionally, any
amounts you pay for excluded drugs do not count toward your total drug costs.
*These drugs are specifically excluded from coverage unless you have had radical
retropubic prostatectomy surgery or certain other medical conditions. Prior authorization is
required.
**Part D covers medications lost or damaged as the direct result of a declared national
disaster or public health emergency.
36 Pharmacy Benefit Information
37
Adrenal Hormone Drugs a-methapred (injection solution reconstituted)
DEPO-MEDROL (injection suspension)
methylprednisolone (oral tablet)
methylprednisolone acetate (injection suspension)
methylprednisolone sodiumsuccinate (injection
solution reconstituted)
prednisolone sodium phosphate (oral solution)
prednisone (oral solution, oral tablet)
PREDNISONE INTENSOL (oral concentrate)
SOLU-MEDROL (injection solution reconstituted)
Anti-Hypertensive Drugs REMODULIN (injection solution)
Anti-Infective Drugs amphotericin b (injection solution reconstituted)
CUBICIN (injection solution reconstituted)
foscarnet sodium (injection solution)
NEBUPENT (inhalation solution reconstituted)
TOBI (inhalation nebulization solution)
vancomycin hcl (injection solution)
Anti-Neoplastic and
Immunosuppressant Drugs
AFINITOR (oral tablet)
azathioprine (oral tablet)
azathioprine sodium (injection solution
reconstituted)
CELLCEPT (oral capsule, oral suspension
reconstituted, oral tablet)
cyclophosphamide (oral tablet)
cyclosporine (oral capsule, injection solution)
cyclosporine modified (oral capsule, oral solution)
gengraf (oral capsule, oral solution)
methotrexate (oral tablet)
mycophenolate mofetil (oral capsule, oral tablet)
MYFORTIC (oral tablet delayed release)
NEORAL (oral capsule, oral solution)
NEXAVAR (oral tablet)
PROGRAF (oral capsule, injection solution)
RAPAMUNE (oral solution, oral tablet)
RHEUMATREX (oral tablet)
RITUXAN (concentrate)
Medications Requiring Prior Authorization (PA)
This List Includes Only Formulary Medications and is Subject to Change
Note: In most instances, new and generic equivalent medications that become available in
the drug categories listed below will automatically require prior authorization. New drug
categories may be added throughout the year.
Pharmacy Benefit Information
Generics are in lower case italics – Brand-names are in all capital letters
38
Anti-Neoplastic and
Immunosuppressant Drugs,
continued
SANDIMMUNE (oral capsule, injection solution,
oral solution)
SUTENT (oral capsule)
tacrolimus (oral capsule)
TARCEVA (oral tablet)
THALOMID (oral capsule)
TORISEL (injection solution)
ZORTRESS (oral tablet)
Cardiovascular, Hypertension,
and Lipid Drugs
nitroglycerin (injection solution)
Erectile Dysfunction Drugs
These medications are specifically
excluded from coverage unless
you have had radical retropubic
prostatectomy surgery.
CAVERJECT (injection solution)
CIALIS (oral tablet)
LEVITRA (oral tablet)
MUSE (oral tablet)
VIAGRA (oral tablet)
Gastroenterology Drugs CIMZIA (kit)
dronabinol (oral capsule)
EMEND (oral capsule)
granisetron (oral tablet)
ondansetron hcl (oral solution, oral tablet)
ondansetron odt (oral tablet dispersible)
REMICADE (injection solution)
ZUPLENZ (film)
Immunology, Vaccines, and
Biotechnology Drugs
ARANESP (injection solution)
AVONEX (kit)
BETASERON (injection solution reconstituted)
ENERIX-B (injection suspension)
EPOGEN (injection solution)
HIZENTRA (injection solution)
LEUKINE (injection solution reconstituted)
NEULASTA (injection solution)
NEUMEGA (injection solution reconstituted)
NEUPOGEN (injection solution)
NORDITROPIN FLEXPRO (injection solution)
NORDITROPIN NORDIFLEX PEN (injection
solution)
OMNITROPE (injection solution)
PRIVIGEN (injection solution)
PROCRIT (injection solution)
REBIF (injection solution)
REBIF TITRATION PACK (injection solution)
RECOMBIVAX HB (injection suspension)
TEV-TROPIN (injection solution reconstituted)
Pharmacy Benefit Information
39
Immunology, Vaccines, and
Biotechnology Drugs
TWINRIX (injection suspension)
VIVAGLOBIN (injection solution)
Miscellaneous Agents levocarnitine (solution, oral tablet)
Miscellaneous Hormones ALDURAZYME (injection solution)
ANADROL-50 (oral tablet)
ANDRODERM (oral tablet)
ANDROGEL (topical gel)
ANDROID (oral capsule)
androxy (oral tablet)
calcitriol (oral capsule, solution)
CEREZYME (injection solution reconstituted)
FABRAZYME (injection solution reconstituted)
SOMAVERT (injection solution reconstituted)
testosterone cypionate (oil)
testosterone enanthate (oil)
ZEMPLAR (oral capsule, injection solution)
Miscellaneous Neurological
Drugs
COPAXONE (kit)
GILENYA (oral capsule)
Non-Narcotic Analgesic Drugs CELEBREX (oral capsule)
Osteoporosis Drugs BONIVA (oral tablet)
Psychotherapeutic Drugs dextroamphetamine sulfate (oral tablet)
dextroamphetamine sulfate er (oral capsule)
FOCALIN XR (oral capsule)
METADATE CD (oral capsule)
methylphenidate hcl (oral tablet)
methylphenidate hcl sr (oral tablet)
PROVIGIL (oral tablet)
RITALIN LA (oral capsule)
Pulmonary Drugs acetylcysteine (inhalation solution)
albuterol sulfate (inhalation nebulization solution)
budesonide (inhalation solution)
cromolyn sodium (inhalation nebulization solution)
ipratropium bromide (inhalation solution)
ipratropium bromide/albuterol sulfate (inhalation
solution)
PERFOROMIST (inhalation solution)
PULMICORT (inhalation suspension)
PULMOZYME (inhalation solution)
XOLAIR (injection solution reconstituted)
Rheumatologic Drugs ENBREL (injection solution)
HUMIRA (kit)
SIMPONI (injection solution)
Pharmacy Benefit Information
40 Pharmacy Benefit Information
Medications Subject to Quantity Limits (QL)
This List Includes Only Formulary Medications and is Subject to Change
Note: Non-formulary medications that are approved for coverage by a prior authorization
can also be limited in quantity. In most instances, new medications and generic equivalent
medications that become available in the drug categories listed below will automatically
have quantity limits. New drug categories may be added throughout the year.
Anticholinergic and Antispasmodic
Drugs
OXYTROL (transdermal biweekly patch)
Antineoplastic and
Immunosuppressant Drugs
AFFINITOR (oral tablet)
NEXAVAR (oral tablet)
REVLIMID (oral capsule)
SPRYCEL (oral tablet)
SUTENT (oral capsule)
TARCEVA (oral tablet)
TASIGNA (oral capsule)
TYKERB (oral tablet)
VANDETANIB (oral tablet)
VIDAZA (injection suspension)
VOTRIENT (oral tablet)
ZOLINZA (oral capsule)
ZYTIGA (oral tablet)
Antiviral Drugs RELENZA DISKHALER (blister inhalation
aerosol powder breath activated)
TAMIFLU (oral capsule)
Diabetic Drugs and Supplies All BD insulin syringes
All insulins: APIDRA, BYETTA,
HUMALOG, HUMULIN, LANTUS,
LEVEMIR, NOVOLIN, NOVOLOG,
SYMLIN
Diagnostic and Miscellaneous Drugs alendronate sodium (40mg oral tablet)
Erectile Dysfunction Drugs:
These medications are specifically
excluded from coverage unless
you have had radical retropubic
prostatectomy surgery.
CAVERJECT (injection solution
reconstituted)
CAVERJECT IMPULSE (injection solution
reconstituted)
CIALIS (oral tablet)
LEVITRA (oral tablet)
MUSE (oral tablet)
VIAGRA (oral tablet)
Estrogen and Progestin Therapy
Drugs
ALORA (biweekly transdermal patch)
CLIMARA PRO (transdermal weekly patch)
COMBIPATCH (transdermal biweekly patch)
DIVIGEL (transdermal gel)
ESTRADERM (transdermal biweekly patch)
estradiol (transdermal weekly patch)
MENOSTAR (transdermal weekly patch)
VIVELLE-DOT (transdermal biweekly patch)
Migraine Therapy Drugs butorphanol tartrate (nasal solution)
MAXALT (oral tablet)
MAXALT-MLT (oral dispersible tablet)
MIGRANAL (nasal solution)
naratriptan hcl (oral tablet)
RELPAX (oral tablet)
sumatriptan succinate (injection solution, oral
tablet)
ZOMIG (nasal solution, oral tablet)
ZOMIG ZMT (oral dispersible tablet)
Miscellaneous Gastrointestinal Drugs CIMZIA (injection kit)
EMEND (oral capsule)
ondansetron hcl (oral tablet)
ondansetron odt (oral dispersible tablet)
SANCUSO (transdermal patch)
ZUPLENZ (film)
Miscellaneous Hormones ANDRODERM (transdermal patch)
ANDROGEL (transdermal patch gel)
calcitonin-salmon (nasal solution)
fortical (nasal solution)
SOMAVERT (injection solution reconstituted)
Miscellaneous Neurological Drugs COPAXONE (injection kit)
GILENYA (oral capsule)
Multiple Sclerosis Therapy Drugs AVONEX (injection kit, vial)
BETASERON (injection solution
reconstituted)
REBIF (injection solution)
Narcotic Analgesic Drugs fentanyl (transdermal 72-hour patch)
Non-Narcotic Analgesic Drugs butorphanol tartrate (nasal solution)
41
Pharmacy Benefit Information
42 Pharmacy Benefit Information
Opthalmic Therapy Drugs RESTASIS (ophthalmic emulsion)
Osteoporosis Therapy Drugs alendronate sodium (oral tablet)
BONIVA (oral tablet)
FORTEO (injection solution)
Psychotherapeutic Drugs EMSAM (transdermal 24-hour patch)
PROVIGIL (oral tablet)
zaleplon (oral capsule)
zolpidem tartrate (oral tablet)
zolpidem tartrate er (oral tablet)
Pulmonary Drugs flunisolide (nasal solution)
fluticasone propionate (nasal suspension)
XOLAIR (injection solution)
Rheumatoid Arthritis Therapy
Drugs
ENBREL (injection kit)
ENBREL (injection solution)
ENBREL SURECLICK (injection solution)
HUMIRA (injection kit)
leflunomide (oral tablet)
SIMPONI (injection solution)
Tobacco Cessation Drugs buproban (oral tablet)
CHANTIX (oral tablet)
NICOTROL INHALER (inhaler)
NICOTROL NS (nasal solution)
Topical Anesthetic Drugs LIDODERM (external patch)
Claim Procedures
Deadline for Filing Claims
Claims must be received by HealthChoice no later than December 31 of the year
following the year claims were incurred. For example, if the date of service was July 1,
2011, the claim is accepted through December 31, 2012.
Filing a Health Claim
Most providers file your claims with Medicare and then automatically file your claims
with HealthChoice. To process your claim electronically, HealthChoice must have your
and your covered dependents’ Medicare numbers on file.
If you have to file your claim with HealthChoice yourself, you must wait until Medicare
sends you an Explanation of Benefits statement for Part A and Part B services. You can file
your claim with HealthChoice by sending a copy of the Explanation of Benefits statement
to:
HP Administrative Services, LLC
P.O. Box 24870
Oklahoma City, OK 73124-0870
Coordination of Health Benefits
If you or your covered dependents have claims that are covered by another group health
plan, HealthChoice benefits are coordinated with your other plan so that total benefits are
not more than the amount billed or your liability. If your other group coverage is primary
over your HealthChoice coverage, you must file claims with your primary plan first. If
your other group coverage terminates, please send written notice to:
HP Administrative Services, LLC
P.O. Box 24870
Oklahoma City, OK 73124-0870
If you have questions about coordination of benefits, please contact HP Administrative
Services, LLC, Monday through Friday, 7:30 a.m. to 6:00 p.m., Central time, at:
1-405-416-1800 or toll-free 1-800-782-5218
TDD users call 1-405-416-1525 or toll-free 1-800-941-2160
43
Claim Procedures
44
Medicare Beneficiaries with End-Stage Renal Disease
If you have End-Stage Renal Disease, Medicare is the secondary payer to your
employer’s group health plan for 30 months. This rule applies regardless of whether you
are a primary member or covered as a dependent under a group health plan. During this
30-month time period, group health plans always pay first.
If you have questions about coverage of End-Stage Renal Disease, visit Medicare's
website at www.medicare.gov or call Medicare, 24 hours a day, 7 days a week, at:
Toll-free 1-800-MEDICARE (1-800-633-4227)
Toll-free TTY/TDD 1-877-486-2048
Filing a Pharmacy Claim
Usually, your claim is processed electronically at the pharmacy. If your pharmacy has
questions, have them contact the Medco Pharmacy Help Line, 24 hours a day, 7 days a
week including holidays, at:
Toll-free 1-800-922-1557 or toll-free TTY/TDD 1-800-825-1230
In some cases, you may need to pay the full cost of your drug and then ask HealthChoice
to repay you for its share. You may need to ask for reimbursement when:
You use a non-Network pharmacy
You pay the full cost for a drug because you did not have your plan ID card
Your drug has a restriction and you decide to purchase the drug immediately
To ask for reimbursement, send your pharmacy receipt and Coordination of Benefits/
Direct Claim Form to:
With Part D – Medco, P.O. Box 14718, Lexington, KY 40512
Without Part D – Medco, P.O. Box 14711, Lexington, KY 40512
While you don’t have to use a Coordination of Benefits/Direct Claim Form, it is helpful.
You can access a form on our website at www.sib.ok.gov or www.healthchoiceok.com
or by calling Medco, 24 hours a day, 7 days a week, at:
With Part D call toll-free 1-800-590-6828 or toll-free TDD 1-800-716-3231
Without Part D call toll-free 1-800-903-8113 or toll-free TDD 1-800-825-1230
If your claim involves other group health insurance, include a copy of the Explanation of
Claim Procedures
45
Benefits statement you received from your other plan. When your request for payment is
received, Medco will let you know if more information is needed to process your claim.
If your claim is for a covered medication and you followed all Plan guidelines,
HealthChoice reimburses you for its share of the cost.
If your claim is for a non-covered medication or you did not follow Plan guidelines,
HealthChoice sends you a letter letting you know the reasons for not sending
reimbursement and what your rights are to appeal the decision.
Coordination of Pharmacy Benefits
If you or a covered dependent have other group pharmacy coverage that is primary over
HealthChoice, your pharmacy can still process your prescription claims electronically at
the time of purchase. If your pharmacy can file claims electronically, show the pharmacist
your HealthChoice Prescription Drug ID card and your primary insurance ID card. If
the pharmacy cannot file your secondary HealthChoice claims electronically, have them
contact the Medco Pharmacy Help Line, 24 hours a day, 7 days a week, at:
Toll-free 1-800-922-1557 or toll-free TTY/TDD 1-800-825-1230
If you have to file a paper claim, see Filing a Pharmacy Claim in this section for
instructions. If you have questions about pharmacy coordination of benefits, please
contact Medco, 24 hours a day, 7 days a week, at:
With Part D call toll-free 1-800-590-6828 or toll-free TDD 1-800-716-3231
Without Part D call toll-free 1-800-903-8113 or toll-free TDD 1-800-825-1230
Claims for Services Outside the United States (see note next page)
When traveling outside the U.S. and its territories, you must pay for your medical
expenses and then ask HealthChoice to pay you back. Your itemized bill must be
translated to English and converted to U.S. dollars using the exchange rates applicable
for the dates of service. Medical claims must be submitted to:
HP Administrative Services, LLC, PO Box 24870, Oklahoma City, OK 73124-0870
For questions about claim filing, call HP Administrative Services, LLC, Monday through
Friday, 7:30 a.m. to 6:00 p.m., Central time, at:
1-405-416-1800 or toll-free 1-800-782-5218
TDD users call 1-405-416-1525 or toll-free 1-800-941-2160
Claim Procedures
46
Note: HealthChoice does not pay for medications purchased outside the United States.
Private Contracts with Physicians and Practitioners
A Private Contract is a written agreement between a Medicare beneficiary and a doctor
or practitioner who does not provide services through the Medicare program. These
providers have opted out of Medicare, and you must sign a Private Contract with them
before they will provide care. If you sign a Private Contract, be aware that:
Medicare’s limiting charge does not apply. You pay what the practitioner charges.
Claims for these services are not covered by Medicare or HealthChoice and neither
Medicare nor HealthChoice pay anything for these services.
Subrogation
Subrogation is a process that is followed when you become sick or injured as a
result of the negligent act or omission of another person or party. Subrogation means
HealthChoice has a right to recover any benefit payments made to you or your
dependents by a third party’s insurer, because of an injury or illness caused by the third
party. Third party means another person or organization.
If you or your covered dependents receive HealthChoice benefits and have a right to
recover payments from a third party, this Plan has the right to recover any benefits paid
on your behalf. All payments from a third party, whether by lawsuit, settlement, or
otherwise, must be used to repay HealthChoice for your health care costs.
You must promptly notify HealthChoice if you file a claim against a third party for any
illness or injury for which HealthChoice benefits have been or will be paid. You or your
dependent must provide all the information HealthChoice requests. HealthChoice benefits
can be withheld until information is received.
Once HealthChoice has the needed information, your covered claims are processed,
regardless of whether a third party is eventually found liable for your health care costs.
For more information about subrogation, please contact OSEEGIB, Monday through
Friday, 7:30 a.m. to 4:30 p.m., Central time, at:
1-405-717-8701 or toll-free 1-800-543-6044
TDD users call 1-405-949-2281 or toll-free 1-866-447-0436
Do not contact the claims office, HP Administrative Services, LLC, regarding
subrogation as this will only delay a response.
Claim Procedures
47
Eligibility,
Enrollment, and Disenrollment
Medicare Eligibility
Medicare is the federal health insurance program for people:
Age 65 and older
Under age 65 with qualified disabilities
With End-Stage Renal Disease
The Centers for Medicare and Medicaid Services (CMS) manage the Medicare program.
The Social Security Administration determines eligibility, enrolls people in Medicare,
and collects Medicare premiums. For information about Medicare, visit the CMS website
at www.cms.gov or the Social Security website at www.ssa.gov. You can also contact
Social Security, Monday through Friday, 7:00 a.m. to 7:00 p.m., Central time, at:
Toll-free 1-800-772-1213 or toll-free TTY/TDD 1-800-325-0778
Medicare is divided into several parts. The parts of Medicare that apply to your Plan
include:
Part A covers services provided by hospitals, skilled nursing facilities, or home
health agencies.
Part B covers most other medical services, such as physician's services, outpatient
services, and durable medical equipment and supplies.
Part D covers prescription drugs.
Enrollment in Medicare
Enrollment in Medicare is handled in two ways – either you are automatically enrolled or
you must apply.
If you receive Social Security or Railroad Retirement Board benefits before you turn 65,
you are automatically enrolled, and your Medicare ID card is mailed to you about three
months before your 65th birthday.
If you are not already receiving Social Security or Railroad Retirement Board retirement
benefits, you must apply for Medicare by contacting the Social Security Administration,
or if appropriate, the Railroad Retirement Board.
Eligibility, Enrollment, and Disenrollment
48
If you have been a disabled beneficiary under Social Security or Railroad Retirement for
24 months, you will automatically get a Medicare ID card in the mail.
When You Become Medicare Eligible
When you become Medicare eligible because you turned 65, you are automatically
enrolled in the corresponding Medicare Supplement Plan With Part D. For example, if
you are a HealthChoice High Option Plan member, you are moved to the High Option
Medicare Supplement Plan With Part D. HealthChoice must have Medicare numbers on
file for you and your covered dependents. To provide this information, send a copy of
your and your dependents’ Medicare ID cards to:
HealthChoice, 3545 NW 58 Street, Suite 110, Oklahoma City, OK 73112
If you become Medicare eligible before age 65 due to a disability, you must complete and
return an Application for Medicare Supplement With Part D to enroll. You are enrolled in
the Plan on the first day of the month following the receipt of your application or on the
effective date of Medicare coverage, whichever is later.
Eligibility Requirements
To enroll in a HealthChoice Medicare Supplement Plan, you must be:
Entitled to Medicare Part A and/or enrolled in Medicare Part B
Listed as eligible in Medicare's system
Reside in the United States or its territories
If you live abroad or you are in prison, you cannot enroll in a plan with Part D; however,
you can enroll in a plan without Part D.
Enrollment Periods
There are three time periods when you can enroll in or disenroll from HealthChoice.
The Initial Enrollment Period – The Initial Enrollment Period refers to the time
you are first eligible to enroll in Medicare. This seven-month period begins three
months before the month you become eligible and extends three months after
the month of your eligibility. For example, Mrs. Smith turns 65 on April 20 and
becomes eligible for Medicare Part A. Her Part B and Part D enrollment period
begins on January 1 and ends on July 31.
The Annual Enrollment Period/Option Period – Medicare has set the dates of
the Annual Enrollment Period/Option Period as October 15 through December 7 of
Eligibility, Enrollment, and Disenrollment
49
each year. The final deadline of December 7 is strictly enforced by Medicare. Once
the annual enrollment period ends, enrollments/disenrollments cannot be made
until the next annual Option Period.
Special Enrollment Periods – Special Enrollment Periods are allowed when:
yyYou enter or leave a skilled nurse facility
yyYou move outside the United States or its territories
yyThe Plans’ participation in the Part D program is terminated
yyYou lose Creditable Coverage for reasons other than failure to pay premiums
yyYou meet other exception rules as set out by CMS
yyYou gain or lose Extra Help
For information on Special Enrollment Periods, contact HealthChoice Member Services,
Monday through Friday, 7:30 a.m. to 4:30 p.m., Central time, at:
With Part D call 1-405-717-8699 or toll-free 1-800-865-5142
Without Part D call 1-405-717-8780 or toll-free 1-800-752-9475
TDD users call 1-405-949-2281 or toll-free 1-866-447-0436
Effective Date of Coverage
Initial Enrollment Period – Effective date is the first of the month you become
Medicare eligible, or the first of the month following the processing of your
application, whichever is later
Annual Enrollment Period/Option Period – Effective date is January 1
Special Enrollment Periods – Effective date always follows the processing of your
application and can never be before that date.
Confirmation Statements
Anytime a change is made to your coverage, you are mailed a Confirmation Statement
(CS). Your CS lists the coverage you are enrolled in, the effective date of coverage, and
the premium amounts. Review your CS as soon as you receive it so any errors can be
corrected as soon as possible.
Dependent Coverage
Dependents can be added to coverage only if one of the following conditions is met:
Your dependent was insured under another group health plan and lost coverage
under that plan. Application for enrollment and proof of the termination of other
group health coverage must be submitted within 30 days of the loss. You must
cover all eligible dependents. Some exceptions apply. See Excluding Dependents
Eligibility, Enrollment, and Disenrollment
50
from Coverage in this section.
You marry and want to add your new spouse and dependent children to your
coverage. You must add them within 30 days of your marriage.
You gain a new dependent through birth, adoption, or legal guardianship. You must
add them within 30 days of the birth, adoption, or gaining legal guardianship.
COBRA continuation of coverage is available for dependents who lose eligibility. See
Consolidated Omnibus Budget Reconciliation Act (COBRA) in this section.
Eligible Dependents
Eligible dependents include:
Your legal spouse (including common-law)
Your daughter, son, stepdaughter, stepson, eligible foster child, adopted child or
child legally placed with you for adoption up to age 26, married or unmarried
A dependent, regardless of age, who is incapable of self-support due to a disability
that was diagnosed prior to age 26; subject to medical review and approval
Other unmarried dependent children up to age 26, upon completion of an
Application for Coverage for Other Dependent Children. Guardianship papers or a
tax return showing dependency may be provided in lieu of the application
You can only enroll dependents in the same type of coverage and in the same plans as
you. Dependents who are not enrolled within 30 days of your eligibility date cannot be
enrolled unless there is a qualifying event such as birth or marriage.
If you drop eligible dependents from coverage, you cannot re-enroll them unless they
lose other group coverage.
If your spouse is enrolled separately in a plan offered through OSEEGIB, your
dependents can be covered under only one parent’s health, dental, and/or vision plan (but
not both); however, both parents can cover dependents under Dependent Life insurance.
Newborn Limited Benefit – Newborns are covered for routine well-baby care for the
first 48 hours following a vaginal delivery or the first 96 hours following a C-section
delivery. Any additional services provided to your newborn that are considered non-routine
are not covered unless you enroll your newborn for the month of the birth and
pay the premium for that month. This means you are responsible for any charges over
and above the Plan's payment of the newborn limited benefit regardless of the facility's
Network or non-Network status. You have 30 days from the date of birth to enroll your
newborn in coverage. A separate calendar year deductible and coinsurance may apply
to the newborn depending on your plan. If you do not enroll your newborn during this
30-day time period, you cannot do so in the future. Your newborn's Social Security
Eligibility, Enrollment, and Disenrollment
number is not required at the time of initial enrollment, but must be provided when it is
received from the Social Security Administration. If you enroll your newborn, insurance
premiums must be paid for the full month of your child's birth.
Excluding Dependents from Coverage
Eligible dependents can be excluded from coverage if they have other group health
coverage or are eligible for Indian or military health benefits. You can exclude eligible
dependent children who do not live with you, are married, or are not financially
dependent on you for support. You can also exclude your spouse. You and your spouse
must both sign the Spouse Exclusion section of your Application for Retiree/Vested/Non-
Vest/Defer Insurance or the Spouse Exclusion section of your Option Period Enrollment/
Change Form if you drop your spouse during the Annual Enrollment Period/Option
Period.
To Request Coverage Changes
All requests for changes in coverage must be made in writing. Verbal requests for
changes are not accepted. Please send all requests for changes to:
HealthChoice
3545 NW 58 Street, Suite 110
Oklahoma City, OK 73112
or fax your request to 1-405-717-8939.
When Your Employer Changes Insurance Carriers
Education Retirees
If you were a career tech employee or a common school employee who terminated
employment on or after May 1, 1993, you can continue coverage through the Plan as
long as the school system from which you retired or vested continues to participate in
the Plan. If your school system terminates coverage with the Plan, you must follow your
former employer to its new insurance carrier.
If you were an employee of an education entity other than a common school (e.g.,
higher education, charter school, etc.), you can continue coverage through the Plan as
long as the education entity from which you retired or vested continues to participate in
the Plan. If your former employer terminates coverage with the Plan, you must follow
your former employer to its new insurance carrier.
51
Eligibility, Enrollment, and Disenrollment
Local Government Retirees
If you were a local government employee who terminated employment on or after
January 1, 2002, you can continue coverage through the Plan as long as the employer
from which you retired or vested continues to participate in the Plan. If your former
employer terminates coverage with the Plan, you must follow your former employer to its
new insurance carrier.
New Employer Retirees
All retirees of employers that joined the Plan after the grandfathered dates listed on the
previous page must follow their former employer to its new insurance carrier.
Following Your Employer to a New Plan
When you terminate employment, your benefits are tied to your most recent employer.
If that employer discontinues participation with OSEEGIB, some or all of their retirees
and dependents (depending on the type of employer) must follow the employer to its
new insurance carrier. This is true regardless of the amount of time you work for any
participating employer. If you retire and then return to work for another employer and
enroll in benefits through that employer, your benefits are tied to your new employer.
If You Return to Work
If you return to work and enroll in a group health plan offered through your employer,
that plan is your primary insurance carrier; however, you may be eligible to continue
your HealthChoice Medicare Supplement Plan as your secondary carrier.*
If you are able to opt out of your employer’s group health plan, Medicare is your primary
insurance carrier, and you may be eligible to continue your HealthChoice Medicare
Supplement Plan as your secondary carrier.*
If you are a retired or vested member returning to work and you did not continue health
coverage at the time you retired or vested, you must meet all the eligibility requirements
of a new employee.
*Be aware that your employer cannot provide a Medicare supplement plan, or pay for
any premiums related to a Medicare supplement plan.
Ending Your Coverage With HealthChoice
Ending your coverage with HealthChoice can be voluntary (your choice) or involuntary
52 Eligibility, Enrollment, and Disenrollment
(not your choice). You can choose to leave the Plan or HealthChoice may be required to
end your coverage.
If you terminate coverage in retirement or as a vested member, you cannot re-enroll in the
Plans offered through OSEEGIB.
If your dependent is dropped from your plan, they cannot be re-enrolled unless they lose
other group coverage.
You have the option to leave the Plan during the Annual Enrollment Period/Option
Period; however, in certain situations, you can leave the Plan at other times of the year,
known as Special Enrollment Periods.
As a retiree, if your health, dental, and/or life coverage is cancelled, it cannot be
reinstated at a later date unless you return to work as an employee of a participating
employer. You will forfeit any retirement system contribution paid toward your health
insurance premium. Vision coverage is not affected by the cancellation rule and can be
elected during the Annual Enrollment Period/Option Period as long as you keep one other
benefit through OSEEGIB.
If you are enrolled in a plan with Part D and you drop your HealthChoice coverage, you
must enroll in another Part D plan within 63 days to avoid a late enrollment penalty.
When HealthChoice Must End Your Coverage
HealthChoice must end your coverage in the Plan when:
You fail to pay premiums
You move out of the United States or its territories for more than 12 months
You go to prison
You lie about or withhold information about other prescription coverage you have*
You continuously behave in a way that is disruptive*
You allow someone else to use your ID card to purchase prescription drugs
*We cannot end your coverage for these reasons unless we first get permission from
Medicare. If HealthChoice ends your coverage, we send you a letter explaining our
reasons and include instructions about how you can file a complaint with the Plan.
In the Event of Your Death
Your surviving dependents can continue any coverage that was in effect at the time of
53
Eligibility, Enrollment, and Disenrollment
your death, as long as all premiums are paid. Surviving dependents have 60 days to notify
HealthChoice they wish to continue their coverage.
If your dependents are enrolled in a plan with Part D, their coverage is continued
automatically; however, they have the option to cancel coverage.
Coverage is retroactive to the first day of the month following your death. Surviving
dependents receive a bill for all past months’ premiums. Claims for medical treatment and
pharmacy purchases must be filed after your survivors are enrolled and premiums are
received.
Notice of your death should be directed to your retirement system and HealthChoice.
Consolidated Omnibus Budget Reconciliation Act (COBRA)
COBRA is federal legislation which gives members and their covered dependents who
lose health benefits the right to choose to continue group health benefits for limited
periods of time under certain circumstances. You and your covered dependents are
eligible to continue coverage for up to 18 months if you lose coverage due to:
A reduction in your hours of employment
Termination of your employment for reasons other than gross misconduct
Your covered spouse and dependent children are eligible to continue coverage for up to
36 months if coverage is lost for reasons such as:
A divorce or legal separation*
Your dependent loses eligibility
Your death (See In the Event of Your Death in this section)
As a former employee, you must notify OSEEGIB in writing within 30 days of a
divorce*, legal separation*, or your child’s loss of dependent status under this Plan.
You and/or your eligible dependents must elect continuation of coverage within 60 days
after the later of the following events occur:
The date the qualifying event would cause you or your dependents to lose coverage
The date OSEEGIB notifies you or your dependents of continuation of coverage
rights
It is the policy of OSEEGIB that for any benefit continued under COBRA, one person
must always pay the primary member premium. In cases where a spouse, child, or
children are insured under a particular benefit and the member did not keep coverage, one
54 Eligibility, Enrollment, and Disenrollment
person will always be billed at the primary member rate.
If you have questions about COBRA, contact HealthChoice Member Services, Monday
through Friday, 7:30 a.m. to 4:30 p.m., Central time, at:
1-405-717-8780 or toll-free 1-800-752-9475
TDD users call 1-405-949-2281 or toll-free 1-866-447-0436
*Oklahoma law prohibits dropping your spouse/dependents in anticipation of a divorce
or legal separation. If you are in the process of a divorce or legal separation, contact your
legal counsel for advice before making changes to your benefits coverage.
55
Eligibility, Enrollment, and Disenrollment
Your Responsibilities
The things you need to do as a HealthChoice member are listed below.
Get familiar with your benefits and the rules you must follow to get covered
services, supplies, and medications.
yyThis handbook provides the information you need to get covered services,
supplies, and medications. Please review it carefully.
Let HealthChoice know if you have other health or prescription drug coverage in
addition to your coverage through HealthChoice.
yyHealthChoice is required to follow rules set by Medicare to make sure
you are using all of your coverage in combination when you get covered
services, supplies, and medications. This is called coordination of benefits
because it involves coordinating benefits you receive from HealthChoice
with any other benefits available to you.
Tell your doctor and pharmacist you are a HealthChoice plan member.
yyShow your HealthChoice ID card to your doctor or pharmacist when you
receive services or medications. This helps to prevent fraud and protects
your benefits.
Help your doctors and other providers by giving them information, asking
questions, and following through on your treatment.
Pay what you owe.
Let HealthChoice know if you move.
yyIf you move outside the HealthChoice service area (the United States and its
territories), you cannot remain a member of the Plan with Part D.
yyIf you move within our service area, the United States and its territories, you
still need to let HealthChoice know so your member record can be updated.
If you have questions or concerns, contact HealthChoice Member Services, Monday
through Friday, 7:30 a.m. to 4:30 p.m., Central time, at:
With Part D call 1-405-717-8699 or toll-free 1-800-865-5142
Without Part D call 1-405-717-8780 or toll-free 1-800-752-9475
TDD users call 1-405-949-2281 or toll-free 1-866-447-0436
56 Your Responsibilities
Your Rights as a HealthChoice Member
Your Medicare prescription drug benefits and your rights and responsibilities are
governed by Oklahoma and federal laws. The primary federal law that applies to this
document is Title XVIII of the Social Security Act and the regulations created under
the Social Security Act by the Centers for Medicare and Medicaid Services (CMS). In
addition, other federal and state laws apply.
For more information about your rights, you can visit www.medicare.gov to read or print
the publication, Your Medicare Rights and Protections. You can also call Medicare, 24
hours a day, 7 days a week, at:
Toll-free 1-800-MEDICARE (1-800-633-4227)
Toll-free TTY/TDD 1-877-486-2048
You Can Make Complaints or ask the Plan to Reconsider Decisions
If you have problems or concerns about your covered services, the following Grievances
and Appeals section tells you what you can do. It gives details about how to deal with
problems and complaints. Regardless of whether you ask for a coverage decision, file an
appeal, or make a complaint, HealthChoice is required to treat you fairly.
Non-Discrimination
HealthChoice must obey laws that protect you from discrimination or unfair treatment.
OSEEGIB does not discriminate based on a person’s race, disability, religion, sex, sexual
orientation, health, ethnicity, creed, age, or national origin when it provides benefits.
Federal laws that prohibit discrimination include Title VI of the Civil Rights Act of
1964, the Rehabilitation Act of 1973, the Age Discrimination Act of 1975, the Americans
with Disabilities Act, and all other laws that apply to organizations that receive federal
funding.
If you want more information or have concerns about discrimination or unfair treatment,
please call the federal Office for Civil Rights at the following numbers:
Toll-free 1-800-368-1019 or toll-free TDD 1-800-537-7697
Timely Access to Covered Drugs
You have the right to get your prescriptions filled or refilled at any Network Pharmacy
57
Your Rights as a HealthChoice Member
without long delays. If you don’t think you are getting your Part D drugs in a reasonable
amount of time, see the Grievances and Appeals section. This section will explain how
you can file a grievance.
Protecting the Privacy of Your Personal Health Information
The laws that protect the privacy of your health information give you certain rights
related to getting information and controlling how your health information is used. Your
personal health information includes the personal information you gave HealthChoice
when you enrolled as well as your medical records and other medical and health
information.
Privacy Notice
This notice describes how medical information about you may be used and disclosed and
how you get access to this information. Please review this notice carefully.
OSEEGIB is a division of the Office of State Finance. OSEEGIB is a State of Oklahoma
governmental agency that is created and governed by Oklahoma law for the purpose
of administering health, life, disability, and dental benefits to state, local government,
and education employees, and other groups designated by statute, including each of the
preceding group’s respective retirees. Oklahoma privacy laws and the federal Health
Insurance Portability and Accountability Act (HIPAA) govern privacy matters between
OSEEGIB and its participants concerning the privacy of an individual member’s health
information. Information contained in an OSEEGIB member’s file is confidential by law
and we at OSEEGIB are committed to protecting the privacy and security of members’
information. This notice describes and gives you examples of how OSEEGIB will use
and disclose your health information and your rights regarding this information.
OSEEGIB uses and discloses your protected health information (PHI) for payment
of services to enable your medical treatment, and for OSEEGIB business operations
in the administration of health plans. The health claims you submit, or health claims
submitted by providers for your treatment, contain protected health information and are
processed for payment and data collection by claims administrators according to contract
terms with OSEEGIB. OSEEGIB and its claim administrators use and disclose your
PHI for payment responsibilities that include: collecting premiums, determination of
medical necessity according to certification procedures, eligibility issues, coordinating
benefits with other insurers, producing Explanations of Benefits, subrogation, and claim
adjudication. Contract terms with each of its claims administrators state that the claims
administrator is a Business Associate as defined in OSEEGIB Rules, with obligations
to protect members’ information. Your health information is used and disclosed by
OSEEGIB employees and other entities under contract with OSEEGIB according
58 Your Rights as a HealthChoice Member
to the “minimum necessary” standard. OSEEGIB or its claims administrators may
use and disclose health information for HealthChoice plan operations that include:
providing customer service, resolving grievances, conducting activities to improve
members health and reduce costs, case management and coordination of care, premium
rate setting activities, law enforcement, public health threats, workers’ compensation/
disability, national security, and as permitted or required by law. OSEEGIB provides
limited member information to participating plan sponsors for enrollment purposes and
premium comparison. OSEEGIB will ask for your written permission before it uses
or discloses your health information for purposes that are not described in this Notice.
You have the right to: a) inspect and copy your health information (generally EOBs),
with the exception of psychotherapy notes and/or information that requires a court
order; b) amend and restrict the health information that OSEEGIB discloses about you;
however, OSEEGIB is not required to agree to a requested restriction; c) request your
communications remain confidential with OSEEGIB; d) receive a copy of this Notice; e)
file a complaint if you believe OSEEGIB improperly used or disclosed your information;
f) request a listing of your protected health information disclosed by OSEEGIB except
that, as a health plan, OSEEGIB is not required to account for disclosures for claims
payment, OSEEGIB business operations, and disclosures you requested pursuant to your
written Authorization; and, g) receive a paper copy of this Notice upon request, if you
received this Notice electronically.
OSEEGIB reserves the right to change the terms of this Privacy Notice and will provide
all interested persons a revised notice either by U.S. Postal Service delivered to the
individual’s mailing address on file with OSEEGIB, or through electronic communication
by posting the revised Privacy Notice on the OSEEGIB website at www.sib.ok.gov and
www.healthchoiceok.com.
If you believe your privacy rights have been violated, call or send a written complaint to
the OSEEGIB HIPAA Information Officer at 3545 NW 58 Street, Suite 110, Oklahoma
City, OK 73112, 1-405-717-8701, toll-free 1-800-543-6044, TDD 1-405-949-2281, toll-free
TDD 1-866-447-0436; the Secretary of the U. S. Department of Health and Human
Services (HHS) at the Office of Civil Rights, 1301 Young Street, Suite 1169, Dallas,
TX 75202, 1-214-767-4056, or submit an electronic complaint according to directions
located on the HHS Office of Civil Rights website. Complaints to HHS must be filed
within 180 days after the date on which you became aware, or should have been aware,
of the violation. No retaliation is allowed against the individual filing a complaint.
Revised 2011
Information the Plan Must Provide to You
You have the right to get several kinds of information from HealthChoice. This Medicare
supplement handbook/Evidence of Coverage provides much of the information you need
59
Your Rights as a HealthChoice Member
concerning your health and pharmacy benefits, eligibility, premiums, and grievances and
appeals processes. It also provides information about the rules you must follow when you
use your prescription drug benefits, as well as why some drugs are not covered by the
Plan.
More information about the HealthChoice Pharmacy Network and coverage of specific
medications is available on our website at www.sib.ok.gov or www.healthchoiceok.com
or contact Medco, 24 hours a day, 7 days a week, at:
With Part D call toll-free 1-800-590-6828 or toll-free TDD 1-800-716-3231
Without Part D call toll-free 1-800-903-8113 or toll-free TDD 1-800-825-1230
Providing Information in a Way That Works For You
HealthChoice is required to provide information in a way that works for you. This
handbook/Evidence of Coverage is printed in a larger type to make it easier to read.
Additionally, a text version of this handbook is available on the HealthChoice website
at www.sib.ok.gov or www.healthchoiceok.com. This Medicare supplement handbook
is also available in CD format at the Oklahoma Library for the Blind and Physically
Handicapped (OLBPH). Contact OLBPH, Monday through Friday, 8:00 a.m. to 5:00 p.m.
with the exception of state holidays, at:
1-405-521-3514 or toll-free 1-800-523-0288
TDD users call 1-405-521-4672
If you are Medicare eligible because of a disability, HealthChoice is required to provide
you information about plan benefits that is accessible and appropriate for you. If you
have trouble getting information about your plan because of problems related to language
or disability, HealthChoice will work with you to provide plan materials in an appropriate
format. Please contact Member Services at:
With Part D call 1-405-717-8699 or toll-free 1-800-865-5142
Without Part D call 1-405-717-8780 or toll-free 1-800-752-9475
TDD users call 1-405-949-2281 or toll-free 1-866-447-0436
If HealthChoice does not respond appropriately to your request, you can file a complaint
with Medicare by calling toll-free 1-800-MEDICARE (1-800-633-4427), 24 hours a day,
7 days a week. TTY users call toll-free 1-877-486-2048.
Support for Your Right to Make Decisions About Your Care
Sometimes people become unable to make health care decision for themselves due to
60 Your Rights as a HealthChoice Member
accidents or serious illness. You have the right to give instructions about what is to be
done if you are not able to make medical decisions for yourself. This means, if you want
to, you can:
Fill out a written form to give someone the legal authority to make medical
decisions for you if you are unable to make decisions for yourself
Provide your doctors written instructions about how you want them to handle your
medical care if you become unable to make decisions for yourself
The legal documents you can use to give your instructions are called advance directives.
These documents are also called a living will or power of attorney for health care.
If you want to use an advance directive, here is what you do:
Get the form*
Fill it out and sign it
Give copies to the appropriate people
Take a copy with you if you are going to be hospitalized
You may also want to consult your attorney or ask them to help you prepare the
document.
*This form is free. For residents of Oklahoma, the form is available through a link
on the Oklahoma Attorney General's website at www.oag.state.ok.us/oagweb.nsf/
AdvanceDirective.
61
Your Rights as a HealthChoice Member
Grievances and Appeals
What to do if you have a complaint, a denied claim, or you disagree with a decision that
has been made about your health or pharmacy benefits. You cannot be disenrolled from
the Plan or penalized in any way for making a complaint, grievance, or appeal.
When Your Claim for Health Benefits is Denied (Plans with and
without Part D)
If your health claim is denied in whole or in part for any reason, you have the right to
have that claim reviewed. A request for review of your denied claim, along with any
additional information you wish to provide, must be submitted in writing to:
Medical Claims Review
P.O. Box 24870
Oklahoma City, OK 73124-0870
or call Monday through Friday, 7:30 a.m. to 6:00 p.m., Central time, at:
1-405-416-1800 or toll-free 1-800-782-5218
TDD users call 1-405-416-1525 or toll-free 1-800-941-2160
If your claim is reviewed and remains denied, you can appeal that decision to the
Grievance Panel. You can submit a request for a Grievance Panel hearing and represent
yourself in these proceedings. If you are unable to submit a request for a Grievance Panel
hearing yourself, only attorneys licensed to practice in Oklahoma are permitted to
submit your hearing request for you or to represent you through the hearing process [75
O.S. Section 310(5)].
All requests for hearings must be filed within one year of the date you are notified of the
denial of a claim, benefit, or coverage. All medical claim reviews and final decisions of
the Grievance Panel are made as quickly as possible. After exhausting claim review and
grievance procedures, an appeal can be pursued in Oklahoma District Court.
The Grievance Panel is an independent review group as established by statute 74 O.S.
Section 1306(6). For more information, contact:
The Legal Grievance Department
3545 NW 58 Street, Suite 110
Oklahoma City, OK 73112
1-405-717-8701 or toll-free 1-800-543-6044
TDD users call 1-405-949-2281 or toll-free 1-866-447-0436
62 Grievances and Appeals
63
When Your Claim for Pharmacy Benefits is Denied —
Plans without Part D
We encourage you to contact us as soon as possible if you have questions, concerns, or
problems related to your prescription drug coverage. If your pharmacy claim is denied
and you have questions concerning the denial, please contact Medco, 24 hours a day, 7
days a week, at:
Toll-free 1-800-903-8113 or toll-free TDD 1-800-825-1230
If you want to appeal a denied pharmacy claim based on clinical criteria provided by your
physician, you can mail or fax your written appeal to:
OSEEGIB Pharmacy Unit
3545 NW 58 Street, Suite 110
Oklahoma City, OK 73112
Fax: 1-405-717-8925
If your appeal is denied, you have the right to file a grievance with OSEEGIB. Please
follow the same procedures used when appealing a denied health claim.
When Your Claim for Pharmacy Benefits is Denied —
Plans with Part D
The following is a summary of the guidelines for filing a Medicare Part D prescription
drug grievance or appeal. A complete Grievance and Appeals Guide for Pharmacy
Benefits is available on our website at www.sib.ok.gov or www.healthchoiceok.com or
by calling HealthChoice Member Services, Monday through Friday, 7:30 a.m. to 4:30
p.m., Central time, at:
1-405-717-8699 or toll-free 1-800-865-5142
TDD users call 1-405-949-2281 or toll-free 1-866-447-0436
Please let us know if you have questions, concerns, or problems related to your Part D
coverage. The contact information for each of the processes can be found in the Who to
Contact About Complaints, Appeals, Grievances, or Coverage Determinations section.
Making a Complaint – Filing a Grievance
The complaint/grievance process is used when you have problems related to the quality
of your care, waiting time, or the customer service you receive. A complaint/grievance
Grievances and Appeals
64
does not involve coverage or payment. The Medicare program sets rules about what
you need to do to make a complaint and what HealthChoice is required to do when a
complaint is received.
Complaints about the quality of care you receive under Medicare are handled by Medco,
HealthChoice, and/or by an independent organization known as the Quality Improvement
Organization (QIO).
There is a Quality Improvement Organization in each state. In Oklahoma, the organization
is called Health Integrity, LLC. Health Integrity has a group of doctors and other health
professionals who are paid by Medicare to check on and help improve the quality of care
for people with Medicare. Following are a few examples of quality of care issues:
You are unhappy about the quality of care you received, for example, you think
your pharmacist provided you with the wrong prescription or the wrong dosage.
You believe someone did not respect your privacy or was rude or disrespectful.
You believe a pharmacist or customer service representative kept you waiting too
long.
You think your hospital stay is ending too soon.
You think your home health care, skilled nursing facility care, or outpatient
rehabilitation care is ending too soon.
Following are some problems that might lead you to file a complaint/grievance:
You feel you are being encouraged to disenroll from HealthChoice.
You believe HealthChoice informational materials are difficult to understand.
HealthChoice doesn’t make a decision about your claim in the required time frame.
You disagree with a HealthChoice decision not to fast track your request for a
coverage determination or redetermination.
HealthChoice fails to forward your case to a certified Independent Review
Organization (IRO) when a decision is not made within the required time frame.
If you want to make a complaint about quality issues with the Part D prescription drug
program, you or your physician can contact Medco, 24 hours a day, 7 days a week, at:
Toll-free 1-800-590-6828 or toll-free TDD 1-800-716-3231
Coverage Decisions
Whenever you ask for coverage of a medication under Medicare Part D, it is called a
coverage decision. An example is when you take your prescription to be filled at the
pharmacy and coverage for your prescription is approved or denied.
Grievances and Appeals
If your request is denied, you can

#2630
E7848_G2000
www.sib.ok.gov or www.healthchoiceok.com
HealthChoice Employer PDP
High and Low Option Plans
With Part D
HealthChoice
High and Low Option Plans
Without Part D
Evidence of Coverage
Plan Year January 1 through December 31, 2012
HealthChoice
Medicare Supplement Plans
Handbook
State Bird, Scissortailed Flycatcher
State Animal, Buffalo State Reptile, Mountain Boomer
Monthly Premiums
HealthChoice Medicare Supplement Plans
January 1, 2012 – December 31, 2012
Medicare Supplement Plan Premiums Per Enrolled Person*
HealthChoice Employer PDP High Option With Part D
$332.54
HealthChoice Employer PDP Low Option With Part D
$273.02
HealthChoice High Option Without Part D
$383.34
HealthChoice Low Option Without Part D
$323.82
COBRA – Medicare Supplement Plan Premiums Per Enrolled Person
HealthChoice Employer PDP High Option With Part D
$332.54
HealthChoice Employer PDP Low Option With Part D
$273.02
HealthChoice High Option Without Part D
$391.01
HealthChoice Low Option Without Part D
$330.30
*The premiums listed above do not reflect contributions from any retirement system. You must pay your full monthly premium (unless you qualify for Extra Help from Medicare) and your Part A , Part B, and/or Part D premiums, if applicable.
Contracting Statement for the Plans With Part D Prescription Drug Coverage
The Oklahoma State and Education Employees Group Insurance Board (OSEEGIB), a division of the Office of State Finance, contracts with the Centers for Medicare and Medicaid Services (CMS), a division of the federal government, to provide Medicare Part D Prescription Drug coverage for its plans with Part D. OSEEGIB is a Medicare approved Part D plan sponsor. Its contract with CMS is renewed annually, and it is not guaranteed beyond the 2012 contract year. OSEEGIB has the right to refuse to renew its contract with CMS or CMS can refuse to renew its contract with OSEEGIB. Termination or non-renewal of the contract will terminate your enrollment in a HealthChoice Employer PDP Medicare Supplement Plan With Part D.
Materials for the Visually Impaired
A text version of this handbook/Evidence of Coverage is available on the HealthChoice website at www.sib.ok.gov or www.healthchoiceok.com. This handbook is also available in CD format at the Oklahoma Library for the Blind and Physically Handicapped (OLBPH). Contact OLBPH, Monday through Friday, 8:00 a.m. to 5:00 p.m. with the exception of state holidays, at:
1-405-521-3514 or toll-free 1-800-523-0288
TDD users call 1-405-521-4672
This publication was printed by the Oklahoma State and Education Employees Group Insurance Board, a division of the Office of State Finance, as authorized by 74 O.S., Section 1301, et seq. 33,500 copies have been printed at a cost of $1.075 each. Copies have been deposited with the Publications Clearinghouse of the Oklahoma Department of Libraries.HealthChoice Medicare Supplement Handbook
Evidence of Coverage
Effective January 1 through December 31, 2012
This HealthChoice handbook/Evidence of Coverage, including the Annual Notice of Change, your enrollment form, Confirmation Statement, and HealthChoice Medicare Formulary, represent our responsibilities to you. This handbook provides details about your health and prescription drug benefits. It explains what is covered and what you pay as a member of the plan. This handbook explains your rights and responsibilities, as well as the rules you must follow to get the services, supplies, and medications you need. This is an important document, so keep it in a safe place. Please note, the HealthChoice Medicare Supplement Plans are often referred to throughout this handbook as the Plan or Plans.
Table of Contents
Plan Identification and Contact Information........................................................................2
Who to Contact About Complaints, Appeals, Grievances, or Coverage Decisions....................3
How Your Plan Will Change for 2012 – Annual Notice of Change ....................................4
Information About Your Premiums......................................................................................6
General Information............................................................................................................10
Summary of HealthChoice High and Low Option Medicare Supplement Plans................14
Pharmacy Benefit Information............................................................................................21
Claim Procedures.............................................................................................................. � 43
Eligibility, Enrollment, and Disenrollment.........................................................................47
Your Responsibilities...........................................................................................................56
Your Rights as a HealthChoice Member..............................................................................57
Grievances and Appeals......................................................................................................62
Fraud, Waste, and Abuse Compliance ................................................................................69
Health Education Lifestyle Planning ..................................................................................70
Notifications.......................................................................................................................71
Plan Definitions...................................................................................................................73Plan Administrator
Oklahoma State and Education Employees Group Insurance Board (OSEEGIB)
A division of the Office of State Finance
Monday through Friday, 7:30 a.m. to 4:30 p.m., Central time
3545 NW 58 Street, Suite 110, Oklahoma City, OK 73112
1-405-717-8701 or toll-free 1-800-543-6044
TDD 1-405-949-2281 or toll-free 1-866-447-0436
HealthChoice Medicare Supplement Plans
Member Services, Monday through Friday, 7:30 a.m. to 4:30 p.m., Central time
With Part D Plans: 1-405-717-8699 or toll-free 1-800-865-5142
Without Part D Plans: 1-405-717-8780 or toll-free 1-800-752-9475
All Members TDD: 1-405-949-2281 or toll-free 1-866-447-0436
Website: www.sib.ok.gov or www.healthchoiceok.com
HealthChoice Health Claims Administrator
HP Administrative Services, LLC, Monday through Friday, 7:30 a.m. to 6:00 p.m., Central time
P.O. Box 24870, Oklahoma City, OK 73124-0870
1-405-416-1800 or toll-free 1-800-782-5218
TDD 1-405-416-1525 or toll-free 1-800-941-2160
HealthChoice Pharmacy Benefit Manager
Medco Customer Service, 24 hours a day/7 days a week
With Part D Plans: Toll-free 1-800-590-6828 or toll-free TDD 1-800-716-3231
Without Part D Plans: Toll-free 1-800-903-8113 or toll-free TDD 1-800-825-1230
Website: www.medco.com
HealthChoice Certification Administrator
APS Healthcare, Monday through Friday, 7:00 a.m. to 7:00 p.m., Central time
P.O. Box 700005, Oklahoma City, OK 73107-0005
Toll-free 1-800-848-8121 or toll-free TDD 1-877-267-6367
Medicare
Customer Service, 24 hours a day/7 days a week
Toll-free 1-800-MEDICARE (1-800-633-4227) or toll-free TTY 1-877-486-2048
Website: www.medicare.gov
Website for Questions and Answers: http://questions.medicare.gov
Social Security Administration
Customer Service, Monday through Friday, 7:00 a.m. to 7:00 p.m., Central time
Toll-free 1-800-772-1213 or toll-free TTY 1-800-325-0778
Website: www.socialsecurity.gov
Plan Identification and Contact Information
2
Calls to HealthChoice received before or after hours, on weekends, or holidays are answered by an automated phone system. Leave a message, including your name and telephone number, and a Member Services Representative will return your call the next business day.3
Plans With Part D
Health Appeals
HP Administrative Services, LLC: Monday through Friday, 7:30 a.m. to 6:00 p.m., Central time
1-405-416-1800 or toll-free 1-800-782-5218
TDD 1-405-416-1525 or toll-free 1-800-941-2160
Pharmacy Coverage Decisions (Prior Authorizations/Exceptions)
Medco, 24 hours a day/7 days a week
Toll-free 1-800-753-2851 or toll-free TDD 1-800-825-1230
Pharmacy Coverage Redeterminations (Appeal Level 1)
HealthChoice Member Services, ask for the Pharmacy Unit
Monday through Friday, 7:30 a.m. to 4:30 p.m., Central time
1-405-717-8699 or toll-free 1-800-865-5142
TDD 1-405-949-2281 or toll-free 1-866-447-0436
Mail or bring your appeal to the HealthChoice Pharmacy Unit at:
OSEEGIB, 3545 NW 58 Street, Suite 110, Oklahoma City, OK 73112
Pharmacy Grievances
HealthChoice Member Services, Monday through Friday, 7:30 a.m. to 4:30 p.m., Central time
1-405-717-8699 or toll-free 1-800-865-5142
TDD 1-405-949-2281 or toll-free 1-866-447-0436
Quality Improvement Organization
Health Integrity, LLC, Monday through Friday, 8:00 a.m. to 7:00 p.m., Eastern time
Toll-free 1-877-772-3379 or toll-free TDD 1-800-855-2880
Email: MEDICinfo@healthintegrity.org
Plans Without Part D
Health Appeals
HP Administrative Services, LLC, Monday through Friday, 7:30 a.m. to 6:00 p.m., Central time
1-405-416-1800 or toll-free 1-800-782-5218
TDD 1-405-416-1525 or toll-free 1-800-941-2160
Pharmacy Appeals
HealthChoice Member Services, ask for the Pharmacy Unit
Monday through Friday, 7:30 a.m. to 4:30 p.m., Central time
1-405-717-8780 or toll-free 1-800-752-9475
TDD 1-405-949-2281 or toll-free 1-866-447-0436
Fax 1-405-717-8925
Mail or bring your appeal to the HealthChoice Pharmacy Unit at:
OSEEGIB, 3545 NW 58 Street, Suite 110, Oklahoma City, OK 73112
Who to Contact About Complaints, Appeals,
Grievances, or Coverage Decisions4
How Your Plan Will Change for 2012
Annual Notice of Change
This Annual Notice of Change provides a summary of the changes in benefits for 2012.
For more specific benefit information, see the Summary of HealthChoice High and Low
Option Medicare Supplement Plans and Pharmacy Benefit Information sections of this
handbook.
Monthly Plan Premiums
Plan Name 2011 2012 Increase
HealthChoice Employer PDP High Option With Part D $308.34 $332.54 $24.20
HealthChoice Employer PDP Low Option With Part D $251.66 $273.02 $21.36
HealthChoice High Option Without Part D $363.06 $383.34 $20.28
HealthChoice Low Option Without Part D $306.38 $323.82 $17.44
Medicare Deductibles
2011 2012 Increase or (Decrease)
Part A ― Hospitalization $1,132.00 $1,156.00 $24.00
Part B ― Medical $ 162.00 $140.00 ($22.00)
Part D ― Prescription Drugs $ 310.00 $320.00 $10.00
HealthChoice Health Benefits
HealthChoice Plans provide supplemental benefits to Medicare Parts A and B. Benefits
are adjusted January 1 of each year to coincide with changes made by Medicare.
HealthChoice Pharmacy Network
The HealthChoice Pharmacy Network includes nearly 60,000 pharmacies across
Oklahoma and throughout the nation. The number of pharmacies in the network equals
or exceeds Medicare’s requirements for pharmacy access in your area. To locate a
HealthChoice Network Pharmacy near you, visit the HealthChoice website at www.sib.
ok.gov or www.healthchoiceok.com or contact Medco, 24 hours a day, 7 days a week at:
With Part D call toll-free 1-800-590-6828 or toll-free TDD 1-800-716-3231
Without Part D call toll-free 1-800-903-8113 or toll-free TDD 1-800-825-1230
Annual Notice of Change
5
Mail Service Pharmacy
Beginning in March 2012, Medicare members who live in Oklahoma will have the option
to purchase their medications through Medco's mail service pharmacy.
Currently, members who live outside Oklahoma already have the option of purchasing
their medications through Medco's mail service pharmacy. Contact Medco at one of the
numbers listed on the previous page for more information about mail service.
HealthChoice Medicare Formulary
There are changes to the HealthChoice Medicare Formulary. Some drugs have been
added to the formulary while other drugs have been removed. Some brand-name drugs
have been replaced with generic drugs. Additionally, some restrictions have been added
to certain drugs.
A comprehensive version of the formulary is available on the HealthChoice website at
www.sib.ok.gov or www.healthchoiceok.com. Click the Member tab in the top menu
and then select Medicare Members, or contact HealthChoice Member Services, Monday
through Friday, 7:30 a.m. to 4:30 p.m., Central time, at:
With Part D call 1-405-717-8699 or toll-free 1-800-865-5142
Without Part D call 1-405-717-8780 or toll-free 1-800-752-9475
TDD users call 1-405-949-2281 or toll-free 1-866-447-0436
HealthChoice Pharmacy Benefits
In accordance with the Centers for Medicare and Medicaid Service's (CMS)
guidelines, the initial coverage limit is increasing from $2,840 to $2,930. See the
Pharmacy Benefit Information section for details.
Certain tobacco cessation products are available for a $0 copay. Additionally,
HealthChoice partners with the Oklahoma Tobacco Settlement Endowment
Trust and Alere Wellbeing to provide members with over-the-counter nicotine
replacement therapy products (patches, gum, and lozenges) and telephone coaching
at no charge. See the Pharmacy Benefit Information section for more information.
For members without Part D, copays for a 30-day fill of specialty medications are
increasing:
yyPreferred medication copays are increasing from $57.50 to $60.00
yyNon-Preferred medication copays are increasing from $115 to $120
Annual Notice of Change
Information About Your Premiums
2012 Medicare Premiums
If you currently pay a premium for Medicare Part A and/or Part B, you must continue to
pay your premiums in order to keep your Medicare coverage. If you do not qualify for
premium-free Part A, you can buy it. The premium for Part A is $451. You must be at
least 65 years old and meet certain other requirements. You can also buy Part A if you are
under age 65 and were once entitled to Medicare because of a disability.
The standard premium for Part B is $99.90. People with higher incomes may pay more.
If you did not sign up for Part B when you first became eligible, your premiums for Part
B may be higher than if you enrolled when you were first eligible. You can delay your
enrollment in Part B if you are still working and have insurance through your employer.
For more information, contact Social Security, Monday through Friday, 7:00 a.m. to 7:00
p.m., Central time, at:
Toll-free 1-800-772-1213 or toll-free TTY/TDD 1-800-325-0778
Paying Your Plan Premiums
You must pay your full monthly premium unless you qualify for Extra Help from
Medicare. Payment of your monthly premium is handled in one of three ways:
Withheld from your retirement check
Withdrawn automatically from your bank account through an automatic draft
Paid directly to OSEEGIB – you will receive a monthly premium statement
COBRA participants must pay premiums directly to OSEEGIB. Your premiums can be
withdrawn automatically from your bank account through an automatic draft, or paid
directly to OSEEGIB – you will receive a monthly premium statement.
Extra Help Paying for Part D Prescription Costs
(Medicare Low Income Subsidy Information)
There is a program available to help people who have limited income and resources as
determined by Social Security. You may be able to get Extra Help paying your monthly
premiums, pharmacy deductibles, and pharmacy copays. This Extra Help also counts
toward your out-of-pocket maximum. If you think you may qualify or want more
information, visit the Social Security website at www.socialsecurity.gov or call Social
6 Information About Your Premiums
Security, Monday through Friday, 7:00 a.m. to 7:00 p.m., Central time, at:
Toll-free 1-800-772-1213 or toll-free TTY/TDD 1-800-325-0778
You can also visit www.medicare.gov, or call Medicare, 24 hours a day, 7 days a week, at:
Toll-free 1-800-MEDICARE (1-800-633-4227)
Toll-free TTY/TDD 1-877-486-2048
After you apply for Extra Help, you will get a letter letting you know whether or not you
qualify and what you need to do next. You may receive full or partial help depending on
your income, family size, and resources.
For the prescription drug portion of your coverage, you pay $0 or a reduced monthly
premium if you qualify for Extra Help. It also helps you pay your prescription drug costs.
If you qualify for Extra Help in 2012, the information below shows the assistance you will
receive for the prescription drug portion of your coverage.
If you qualify for full help, the following benefits apply:
A premium reduction of $31.10
No pharmacy deductible
Continuous coverage (no Coverage Gap)
Maximum copays of $2.60 for generic/Preferred drugs and $6.50 for other drugs
If you qualify for partial help, the following benefits apply:
A premium reduction between $7.80 and $31.10
A pharmacy deductible of $65
Continuous coverage (no Coverage Gap)
Coinsurance of 15% (up to the out-of-pocket maximum)
If you qualify for Extra Help, Medicare notifies HealthChoice and then HealthChoice
notifies you of the amount of Extra Help you will receive.
Note: Extra Help applies to either the High or Low Option Plans with Part D. If you
qualify for Extra Help, HealthChoice will automatically move you to the Low Option Plan
so you pay the lowest premium. If you want to elect the High Option Plan, please notify
HealthChoice in writing at:
HealthChoice
3545 NW 58 Street, Suite 110
Oklahoma City, OK 73112
7
Information About Your Premiums
8
Your request can also be faxed to 1-405-747-8939.
Be aware that if you qualify for Extra Help, some of the information in this handbook/
Evidence of Coverage will not apply to you.
If you qualify for Extra Help and believe you are paying an incorrect copay amount,
HealthChoice will work with CMS to verify your copay level. If it is determined that
your copay is incorrect, the Plan will update its system so that you pay the correct copay.
If you paid a higher copay than you should have, HealthChoice will pay you back.
Note to members who live in a long-term care facility: If the pharmacy hasn’t
collected copays from you and is carrying your copays as a debt you owe, HealthChoice
can make payment directly to the pharmacy.
Your Premium for Part D Could be Higher –
Part D Income-Related Premium Adjustment
As a member of a Medicare supplement plan offered through OSEEGIB, your premium
for Part D prescription drug coverage is included in your monthly premium. If your
income is above a certain level ($85,000 for individuals or $170,000 for married
couples), you must pay an additional premium for your Part D coverage. If you have to
pay an extra amount, the Social Security Administration will send you a letter telling
you the amount. For more information, call Social Security at 1-800-772-1213, Monday
through Friday, 7 a.m. to 7 p.m., Central time. TTY users call toll-free 1-800-325-0778.
If you fail to pay any Part D income-related premium adjustment, HealthChoice must
move you to a plan without Part D.
Changes in Your Monthly Premium
Generally, your premium does not change during the year; however, in certain cases, a
premium change can occur if:
You do not currently get Extra Help but you qualify for it during the plan year,
your monthly premium will decrease.
You currently get Extra Help but the amount of help you qualify for changes, your
premium will be adjusted up or down.
You add or drop dependents to or from your coverage sometime during the plan
year, your premium will increase or decrease.
For more information, see the 2012 Medicare and You handbook, visit www.medicare.
gov, or call Medicare, 24 hours a day, 7 days a week, at the following numbers: Information About Your Premiums
Toll-free 1-800-MEDICARE (1-800-633-4227)
Toll-free TTY/TDD 1-877-486-2048
Late Enrollment Penalty
Medicare applies a late enrollment penalty to your Part D premium when:
You don’t join a Medicare Part D plan, or other plan with creditable prescription
drug coverage, when you first become Medicare eligible at age 65 or when you
become eligible prior to age 65 due to a disability
You have a lapse in creditable prescription drug coverage that lasts longer than 63
continuous days
The late enrollment penalty is applied at the time you enroll in creditable prescription
drug coverage. The penalty is calculated based on the number of months you were
without Creditable Coverage and the amount of the average monthly premium for Part
D plans. The amount of the penalty can change from year to year, and once a penalty is
applied, it will follow you as long as you have Part D prescription drug coverage.
OSEEGIB pays the late enrollment penalty if it applies to a HealthChoice member, but
the penalty could be applied if you leave OSEEGIB and enroll in another insurance plan.
In some cases, you do not have to pay a penalty even though your enrollment is late. The
penalty is not applied if you:
Have creditable prescription drug coverage through another group or government
plan like TRICARE, Veterans Administration, or Indian Health Services
Were without Creditable Coverage for less than 63 days
Receive Extra Help from Medicare
If you become Medicare eligible because of a disability, the late enrollment penalty is
eliminated when you reach your Initial Enrollment Period at age 65 as long as you remain
enrolled in a Part D plan.
If you have questions about the late enrollment penalty, please contact Medicare toll-free
at 1-800-MEDICARE (1-800-633-4227) or toll-free TTY 1-877-486-2048.
Non-Payment of Premiums
If your monthly plan premiums are late, HealthChoice notifies you in writing that you
must pay your premium by a certain date, which includes a grace period, or we will end
your coverage. HealthChoice has a grace period of two months. See When HealthChoice
Must End Your Coverage in the Eligibility, Enrollment, and Disenrollment section.
9
Information About Your Premiums
10
General Information
This Medicare supplement handbook/Evidence of Coverage provides a guide to the
features of the Plans. It is not a complete description of the Plans. Please read this
handbook carefully for information about eligibility rules and benefits. These Plans are
designed to provide supplemental benefits to Medicare Part A and Part B, as well as Part
D prescription drug benefits. Except as noted otherwise in this handbook, services
not covered by Medicare are not covered by the Plans. The Plans' medical benefits
are based on Medicare’s approved amounts. For more information, review your 2012
Medicare & You handbook, visit www.medicare.gov, or call Medicare, 24 hours a day, 7
days a week, at:
Toll-free at 1-800-MEDICARE (1-800-633-4227)
Toll-free TTY 1-877-486-2048
All HealthChoice medical benefits are paid as if you are enrolled in both Medicare Part
A and Part B. If you are not enrolled in Medicare, HealthChoice estimates Medicare’s
benefits and provides coverage as if Medicare were your primary insurance carrier.
For complete information about Medicare enrollment, visit the Social Security
Administration website at www.socialsecurity.gov or contact Social Security customer
service, Monday through Friday, 7:00 a.m. to 7:00 p.m., Central time, at:
Toll-free 1-800-772-1213
Toll-free TTY/TDD 1-800-325-0778
Other websites that can be helpful are the Centers for Medicare and Medicaid Services at
www.cms.gov or Medicare Questions and Answers at http://questions.medicare.gov
The Plans With Part D
The Plans with Part D benefits include Medicare Part D prescription drug coverage.
The Plans Without Part D
The Plans without Part D include pharmacy benefits, but they are not Medicare Part D plans.
These plans are specifically for members who:
Already have Medicare Part D coverage through another plan or employer
Receive a subsidy for prescription drug benefits from their or their spouse’s
employer
Receive Veterans Administration health benefits for prescription drugs
General Information
Note: Premiums for the plans without Part D are higher because HealthChoice does not
receive a subsidy from Medicare for members enrolled in these plans.
Provider-Patient Relationship
Your provider is responsible for the medical advice and treatment they provide, or any
liability resulting from that advice or treatment. Although a provider may recommend or
prescribe a service or supply, this does not of itself establish coverage by the Plans.
Federal Limiting Charge
Providers who do not accept Medicare assignment cannot charge a Medicare beneficiary
more than 115% of Medicare approved amounts. For more information, refer to the section
of your Medicare and You handbook titled Keeping Your Costs Down with Assignment.
Certification
Certification through the HealthChoice certification administrator, APS Healthcare, is
required for inpatient hospital admissions and certain outpatient surgical procedures if
Medicare is not your primary carrier. If you have questions, contact APS Healthcare,
Monday through Friday, 7:00 a.m. to 7:00 p.m., Central time, at:
Toll-free at 1-800-848-8121 or toll-free TDD 1-877-267-6367
The HealthChoice Plans Supplement Medicare Part A
(hospitalization) by:
Paying the inpatient hospitalization deductible and coinsurance in full
Paying for an additional 365 lifetime reserve days for hospitalization
Paying the Part A coinsurance for skilled nurse facility care for days 21 through 100
Paying for the first three pints of blood while hospitalized
The HealthChoice Plans Supplement Medicare Part B (medical) by:
Paying the 20% of medical expenses not paid by Part B*
Paying the 20% of durable medical equipment expenses not paid by Part B*
Paying for some prescription drugs
*You must pay the Part B deductible before Medicare or HealthChoice pays benefits.
11
General Information
12
The HealthChoice Plans Provide Prescription Drug Coverage
2012 Plan Year Low Option Plan High Option
Plan
Pharmacy Deductible $ 320.00 Not Applicable
Cost Sharing/Copay
The next $2,610.00
in prescription costs
You pay 25% or $652.50
Plan pays 75% or $1,957.50
Applicable copay
per prescription
fill
Coverage Gap $3,727.50* Not Applicable
Annual Out-of-Pocket Maximum $4,700.00 $4,700.00
After Annual Out-of-Pocket Maximum 100% 100%
*Members with Part D who reach $2,930 in total drug costs receive certain discounts
when purchasing covered medications. See Medicare Coverage Gap Discount Program
in the Pharmacy Benefit Information Section.
Plan ID Cards
There are two ID cards; one card is for health and dental benefits and the other card is
for pharmacy benefits. If you are currently a HealthChoice member, continue using your
current ID cards. If you are new to HealthChoice, you are issued new ID cards.
Health/Dental ID Card
Please present your HealthChoice health/dental ID card when you receive services. When
you receive health services, you also need to present your red, white, and blue Medicare
card to your provider. Following is an example of your health/dental ID card:
To request replacement health/dental ID cards, contact HP Administrative Services, LLC,
Monday through Friday, 7:30 a.m. to 6:00 p.m., Central time, at:
1-405-416-1800 or toll-free 1-800-782-5218
TDD users call 1-405-416-1525 or toll-free 1-800-941-2160
General Information
Sample
Sample
Prescription Drug ID Card
Please present your HealthChoice prescription drug ID card when you purchase
prescriptions. The pharmacy automatically bills HealthChoice for its share of your
covered prescription drug cost. You do not need to present your Medicare ID card at the
pharmacy. Following is a sample of your prescription drug ID card:
If you don’t have your prescription drug ID card when you fill a prescription, have your
pharmacy contact HealthChoice for your information. If your pharmacy cannot get the
needed information, you may have to pay for your medication and then ask HealthChoice
to pay you back by filing a paper pharmacy claim. See the Claim Procedures section.
To request a replacement prescription drug ID card, visit www.medco.com. You can also
request a replacement card by calling Medco, 24 hours a day, 7 days a week:
With Part D call toll-free 1-800-590-6828 or toll-free TDD 1-800-716-3231
Without Part D call toll-free 1-800-903-8113 or toll-free TDD 1-800-825-1230
Explanation of Benefits (EOB)
Each time a claim is processed, the health claims administrator sends you an EOB which
explains how your benefits are applied. EOBs are also available online by going to the
HealthChoice website at www.sib.ok.gov or www.healthchoiceok.com and clicking
ClaimLink. If you haven’t registered to access ClaimLink, you will need to create a user
name and password to gain access to your information. If you prefer to go paperless and
not receive paper EOBs, contact the health claims administrator. Also, see Pharmacy
Explanation of Benefits (EOB) in the Pharmacy Benefit Information section.
Your Contact Information
It is important to keep your contact information current. You risk delaying claims
processing, missing communications, and even disenrollment from the Plan when your
information is incorrect. Additionally, Medicare requires that you report any changes
in your name, address, or telephone number to your insurance plan. Changes can be
faxed to 1-405-717-8939 or sent in writing to:
HealthChoice, 3545 NW 58 Street, Suite 110, Oklahoma City, OK 73112
13
General Information
Sample
Sample
14
Services
or Items
Medicare
Part A Pays
HealthChoice Pays
You
Pay
Hospitalization:
Semiprivate room, meals, drugs as part of your inpatient treatment, and other hospital services and supplies
First 60 days
All except $1,156, the Part A deductible
$1,156, the Part A deductible
0%
Days 61 through 90
All except $289 per day
$289 per day
0%
Days 91 and after
while using Medicare's 60 lifetime reserve days
All except $578 per day
$578 per day
0%
Once Medicare’s lifetime reserve days are used, HealthChoice provides additional lifetime reserve days Limited to 365 days
0%
100%
of Medicare eligible expenses
Certification by HealthChoice is required
0%
Beyond the additional 365 days
0%
0%
100%
Skilled Nurse Facility Care:
Must meet Medicare requirements, including inpatient hospitalization for at least 3 days and entering a Medicare approved facility within 30 days of leaving the hospital. Limited to 100 days per calendar year
First 20 days
All approved amounts
0%
0%
Days 21 through 100
All except $144.50 per day
$144.50 per day
0%
Days 101 and after
0%
0%
100%
Medicare Part A (Hospitalization) Services
All benefits are based on Medicare Approved Amounts
Summary of HealthChoice High and Low Option
Medicare Supplement Plans Supplemental Benefits for Medicare Part B (Medical)
All Benefits are Based on Medicare Approved Amounts
15
Medicare Part A Continued
Services
or Items
Medicare
Part A Pays
HealthChoice Pays
You
Pay
Hospice Care
Available as long as your doctor certifies you are terminally ill and you elect to receive these services
All but very limited coinsurance for outpatient drugs and inpatient respite care
0%
Balance
Blood
Limited to the first 3 pints unless you or someone else donates blood to replace what you use
0%
100%
0%
Services
or Items
Medicare Part B Pays
HealthChoice Pays
You
Pay
Medical Expenses:
Inpatient and outpatient hospital treatment, such as physician services, medical and surgical services and supplies, physical and speech therapy, and diagnostic tests (Medicare limits apply)
You pay $140, the Part B deductible
0%
0%
$140, the Part B deductible
Remainder of Medicare approved amounts
80%
20%
0%
Part B charges above Medicare approved amounts
0%
100%
0%
Clinical Laboratory Services
Blood tests and urinalysis for diagnostic services
100%
0%
0%
Home Health Care:
Medicare approved services
Medically necessary skilled care services and medical supplies
100%
0%
0%16
Medicare Part B Continued
Services
or Items
Medicare Part B Pays
HealthChoice Pays
You
Pay
Durable Medical Equipment:
Items such as wheelchairs, walkers, and hospital beds
You pay $140, the Part B deductible
0%
0%
$140, the Part B deductible
Remainder of Medicare approved amounts
80%
20%
0%
Blood
Amounts in addition to the coverage under Part A unless you or someone else donates blood to replace what you use
80% after the Part B deductible
20% after the Part B deductible
0%
Hospice
Prescription
Covered for Medicare beneficiaries with a terminal illness
80%
20%
0%
The $140 Medicare Part B deductible is credited towards your HealthChoice deductible upon receipt of Medicare’s Explanation of Benefits (EOB). Once you meet the Part B deductible, your HealthChoice deductible is met for the plan year.
Medicare Part B - Preventive Services
Preventive Services
Who is Covered
Medicare
Part B
Pays
HealthChoice Pays
You
Pay
One-time Initial Wellness Physical Exam:
To be completed within 12 months of your enrollment in Medicare Part B
All Medicare beneficiaries
100%
No Part B deductible
0%
0%Medicare Part B - Preventive Services Continued
17
Preventive Services
Who is Covered
Medicare
Part B
Pays
HealthChoice Pays
You
Pay
Preventive Exam:
Limited to one every 12 months
All Medicare beneficiaries
100%
No Part B deductible
0%
0%
Screening Mammogram:
Limited to one every 12 months
All female Medicare beneficiaries age 40 and older
100%
No Part B deductible
0%
0%
Cardiovascular Screenings:
Limited to one every five years
All Medicare beneficiaries
100%
No Part B deductible
0%
0%
Pap Test and Pelvic Exam:
Limited to one every 24 months; includes a clinical breast exam
Limited to one every 12 months if high risk/abnormal Pap test in preceding 36 months
All female Medicare beneficiaries
100%
No Part B deductible
0%
0%
Diabetes Screening Test:
Limited to two per year
All Medicare beneficiaries at risk of diabetes
100%
No Part B deductible
0%
0%
Diabetes
Self-Management Training
All Medicare beneficiaries with diabetes (insulin and non-insulin users)
80% after the
Part B deductible
20% after the
Part B deductible
0%
Diabetes Monitoring Supplies:
Includes coverage for glucose monitors, test strips, and lancets without regard to the use of insulin
All Medicare beneficiaries with diabetes - must be requested by your doctor
80% after the Part B deductible
20% after the
Part B deductible
0%18
Medicare Part B - Preventive Services Continued
Preventive
Services
Who is
Covered
Medicare
Part B Pays
HealthChoice Pays
You
Pay
Ostomy Supplies: Includes ostomy bags, wafers, and other ostomy supplies
All Medicare beneficiaries in need of ostomy supplies
80% after the Part B deductible
20% after the
Part B deductible
0%
Colorectal Cancer Screening
Fecal Occult Blood Test: Limited to one every 12 months
Flexible
Sigmoidoscopy:
Limited to one every 48 months for age 50 and older; for those not at high risk, 10 years after a previous screening
Colonoscopy:
Limited to one every 24 months if you are at high risk for colon cancer; if not, once every 10 years, but not within 48 months of a screening flexible sigmoidoscopy
Barium Enema: Doctor can substitute for sigmoidoscopy or colonoscopy
All Medicare beneficiaries age 50 and older
100%
No Part B deductible
0%
0%
All Medicare beneficiaries age 50 and older
100%
No Part B deductible
0%
0%
All Medicare beneficiaries; there is no minimum age
100%
No Part B deductible
0%
0%
All Medicare beneficiaries age 50 and older
100%
No Part B deductible
0%
0%
Prostate Cancer Screening
Digital Rectal Exam: Limited to one every 12 months
Prostate Specific Antigen Test (PSA): Limited to one every 12 months
All male Medicare beneficiaries age 50 and older
80% for the digital rectal exam, after the Part B deductible
20% for the digital rectal exam
0%
100%
No Part B deductible
0%
0%19
Services
Who is Covered
Medicare
Part B Pays
HealthChoice Pays
You
Pay
Bone Mass Measurements:
Limited to one every 24 months
All Medicare beneficiaries at risk for losing bone mass
100%
No Part B deductible
0%
0%
Glaucoma Screening: Limited to one every 12 months; must be performed or supervised by an eye doctor who is authorized to do this within the scope of their practice
Medicare beneficiaries
at high risk or having a family history of glaucoma
80% after the Part B deductible
20% after the Part B deductible
0%
Smoking Cessation:
Eight face-to-face visits in a 12-month period
All Medicare beneficiaries
80% after the Part B deductible
20% after the Part B deductible
0%
HIV Screening:
Limited to once every 12 months or up to three times during pregnancy
Pregnant, high risk, or any Medicare beneficiary who requests the test
100% after the Part B deductible
0%
0%
Medicare Part B - Preventive Services Continued
Vaccinations Covered Under Medicare
Some vaccines are covered under Medicare Part B and others are covered under Medicare Part D. What you pay depends on the type of vaccine, where you purchase the vaccine, and who administers the vaccination shot. The rules for coverage of vaccinations can be complicated. If you are not sure how your vaccination is covered, before you go for your vaccination, you may want to contact HealthChoice Member Services, Monday through Friday, 7:30 a.m. to 4:30 p.m., Central time, at:
Members with Part D call 1-405-717-8699 or toll-free 1-800-865-5142
Members without Part D call 1-405-717-8780 or toll-free 1-800-752-9475
TDD users call 1-405-949-2281 or toll-free 1-866-447-043620
Services Covered Only by HealthChoice
Services
Benefits
Medicare
Part B Pays
HealthChoice Pays
You
Pay
Foreign Travel:
Medically necessary emergency care services beginning during the first 60 days of each trip outside the U.S.A.
Contact
Medicare for
foreign travel
exceptions that are covered by Medicare
0%
80% of billed charges after the first $250 of each calendar year
$50,000 lifetime
maximum
First $250 of each calendar year, then 20% and all amounts over the $50,000 lifetime max
No Medicare deductible
Vaccinations Covered Under Medicare Part B
Flu Vaccination:
Limited to one per flu season
Medicare Part B covers the vaccination and administration at 100% if the provider accepts Medicare assignment.
Pneumococcal Vaccination:
One-time vaccination
Medicare Part B covers the vaccination and administration at 100% if the provider accepts Medicare assignment.
Hepatitis B Vaccination:
Limited to beneficiaries at medium to high risk for Hepatitis B
Medicare Part B covers the vaccination and administration at 100% if the provider accepts Medicare assignment.
Shingles Vaccination:
e.g., ZOSTAVAX (zoster vaccine live)
The vaccine and the administration fee are not covered under Part B. See the Pharmacy Benefit Information section for coverage information.
Tetanus Vaccination:
e.g., TETANUS TOXOID
Covered only for those not immunized, following acute injury
Medicare Part B covers the vaccination and administration at 100% if the provider accepts Medicare assignment.21
What You and HealthChoice Pay for Covered
Prescription Drugs Purchased at Network Pharmacies
Medications Purchased at
Network Pharmacies
You
Pay
HealthChoice
Pays
Generic (Tier 1) and Preferred (Tier 2)
medications costing $100 or less
Copay up to $30
per fill
Allowed Charges after
your copay
Generic (Tier 1) and Preferred (Tier 2)
medications costing more than $100
Copay of 25% up
to $60 per fill
Allowed Charges after
your copay
Non-Preferred (Tier 3) medications
costing $100 or less
Copay up to $60
per fill
Allowed Charges after
your copay
Non-Preferred (Tier 3) medications
costing more than $100
Copay of 50% up
to $120 per fill
Allowed Charges after
your copay
Preferred (Tier 5) prescription tobacco
cessation medications
Copay of $0 per fill Allowed Charges
Preferred, high-cost (Tier 4) medications have the same copays as the generic (Tier 1)
and Preferred (Tier 2) medications. Some medications require Prior Authorization.
See Prior Authorization later in this section.
The High Option plans do not have a pharmacy deductible.
Pharmacy benefits may cover up to a 34-day supply or 100 units, whichever is greater.
See Quantity Limits later in this section.
If you take a specialty medication, see Specialty Medications later in this section.
High Option with Part D plan members who reach total drug costs of $2,930 receive
a 50% discount toward their copay costs when purchasing covered brand-name
medications. See Medicare Coverage Gap Discount Program later in this section.
After You Reach the Pharmacy Out-of-Pocket Maximum
After You Pay HealthChoice Pays
$4,700, the pharmacy out-of-pocket
maximum, in prescription drug copays
100% of covered medications for the
remainder of the calendar year once you
reach the $4,700 pharmacy out-of-pocket
maximum
Pharmacy Benefits for HealthChoice
High Option Medicare Supplement Plans
Pharmacy Benefit Information
22
What You and HealthChoice Pay for Covered
Prescription Drugs Purchased at Network Pharmacies
Pharmacy
Deductible
Stage
$320
Initial Coverage
Limit Stage
$2,610
Coverage
Gap Stage
$3,727.50
100%
Benefit
Stage
After $4,700
During the
Deductible
stage, you must
pay the full cost
of your covered
prescription
drugs, up to
$320, before
HealthChoice
begins to pay.
During the Initial
Coverage Limit stage,
you and HealthChoice
share the costs of the
next $2,610 of covered
prescription drugs
purchased at Network
Pharmacies. You pay 25%,
or a total of $652.50, and
HealthChoice pays 75%,
or a total of $1,957.50.
You pay your 25% each
time you fill a covered
prescription drug at a
Network Pharmacy. For
example, if your drug
costs $60, you pay $15.
During the
Coverage Gap
stage, you pay
100% of the
next $3,727.50
of covered
prescription
drugs purchased
at Network
Pharmacies (less
discounts for
members with Part
D) until you reach
the pharmacy
out-of-pocket
maximum of
$4,700.
During
the 100%
Benefit stage,
HealthChoice
pays 100%
of Allowed
Charges
for covered
prescription
drugs
purchased
at Network
Pharmacies for
the rest of the
calendar year.
To reach the 100% Benefit stage, you must pay the following costs:
1. $ 320.00 the Pharmacy Deductible stage
2. $ 652.50 your 25% of costs during the Initial Coverage Limit stage
3. $3,727.50 your costs during the Coverage Gap stage
Low Option with Part D members who reach total drug costs of $2,930 receive a 50%
discount on the cost of covered brand-name medications, and HealthChoice pays 14% of
the cost of generic medications. See Medicare Coverage Gap Discount Program later in
this section.
Pharmacy benefits may cover up to a 34-day supply or 100 units, whichever is greater.
See Quantity Limits later in this section.
For information on the copays for specialty medications, see Specialty Medications later
in this section.
Pharmacy Benefits for HealthChoice
Low Option Medicare Supplement Plans
Pharmacy Benefit Information
Your Prescription Drug Coverage
Basic Rules for Prescription Drug Coverage
HealthChoice generally covers your drugs as long as you follow these basic rules:
You must have a prescription written by your physician or other provider.
You must use a HealthChoice Network Pharmacy.
Your drug must be on the HealthChoice Medicare Formulary (drug list).
Your drug must be prescribed for a medically accepted indication. This means the
drug is either approved by the Food and Drug Administration or accepted as the
standard of good practice within the medical community.
Pharmacy Out-of-Pocket Maximum
All Plans have a pharmacy out-of-pocket maximum of $4,700. This total includes
amounts you spend on deductibles, copays, and coinsurance at Network Pharmacies. If
you are a Low Option Plan member, this total includes amounts you spend during the
Coverage Gap stage. Once you reach the $4,700 out-of-pocket maximum, the Plan pays
100% for covered medications purchased at Network Pharmacies for the remainder of the
calendar year.
Costs That Apply To the Pharmacy Out-of-Pocket Maximum
Medicare has rules about what does and what does not count toward your pharmacy
out-of-pocket maximum. Medications must be covered Part D drugs and listed on the
HealthChoice Medicare Formulary, or covered through one of the exceptions or appeals
processes. Drugs must be purchased at Network Pharmacies for costs to apply to the out-of-
pocket maximum. The following costs count toward your out-of-pocket maximum:
Your deductible, if applicable
Your coinsurance or copays
Your costs during the Coverage Gap stage (Low Option Plans)
Amounts discounted by brand-name drug manufacturers once you reach $2,930 in
total prescription drug costs
Costs That Do Not Apply To the Pharmacy Out-of-Pocket Maximum
Amounts paid by HealthChoice for generic medications once you reach $2,930 in
total prescription drug costs (Low Option Plans with Part D)
23
Pharmacy Benefit Information
24
Costs for medications purchased outside the United States and its territories
Costs for non-covered medications
Costs for medications purchased at non-Network pharmacies when requirements are
not met
Costs for medications covered under Medicare Part A or Part B
Payments made by another group health plan or government health plan such as
TRICARE, the Veterans Administration, or Indian Health Services
Payments for medications made by a third-party with a legal obligation to pay
Pharmacy Coverage Gap Stage (Low Option Plans)
After your total drug costs reach the Initial Coverage Limit stage ($2,930), you pay
the costs of Part D covered drugs (minus discounts) until you reach the out-of-pocket
maximum of $4,700. This period is known as the Coverage Gap stage.
Medicare Coverage Gap Discount Program (With Part D Plans)
Part D plan members who do not receive Extra Help and reach total drug costs of $2,930
are provided discounts on certain Part D drugs purchased at Network Pharmacies.
Prescription drug manufacturers provide discounts on brand-name drugs, and
HealthChoice provides discounts on generic drugs.
The amounts discounted by brand-name manufacturers apply to your pharmacy out-of-pocket
maximum; however, amounts discounted by HealthChoice do not. Discounts are
automatically applied at your pharmacy when you reach $2,930 in drug costs.
Low Option Plans with Part D: After your total drug costs reach $2,930 ($320
deductible plus $2,610 in additional drug costs), brand-name drug manufacturers
provide a 50% discount* toward the cost of covered brand-name medications, and
HealthChoice pays 14% toward the cost of generic drugs.
High Option Plans with Part D: After your total drug costs reach $2,930, brand-name
manufacturers provide a 50% discount* toward your copay amounts for
covered brand-name medications.
*The 50% discount is available only for brand-name drugs whose manufacturers have
agreed to pay it. If a brand-name manufacturer has not agreed to pay the discount,
medications made by that manufacturer are not covered.
HealthChoice Pharmacy Network
In most cases, your prescriptions are covered only if they are filled at a Network
Pharmacy. The HealthChoice Pharmacy Network includes more than 900 pharmacies
Pharmacy Benefit Information
25
across Oklahoma and nearly 60,000 pharmacies nationwide. It also includes a mail service
option. Network Pharmacies contract with our Plans to provide covered prescription drugs
to members. They also provide electronic claim processing, so generally, there are no
paper claims to file.
The HealthChoice Pharmacy Network includes specialized pharmacies such as:
Pharmacies that supply drugs for home infusion therapies.
Pharmacies that supply drugs to residents of long-term care facilities. Usually,
each long-term care facility has its own pharmacy, and residents can get their
prescription drugs through their facility's pharmacy as long as it is in the
HealthChoice Pharmacy Network.
Pharmacies that serve the Indian Health Service/Tribal/Urban Indian Health
Program.
Sometimes a pharmacy leaves the Network. When this occurs, you have to get your
prescriptions filled at another Network Pharmacy. To locate a HealthChoice Network
Pharmacy near you, go to the HealthChoice website at www.sib.ok.gov or www.
healthchoiceok.com. Click Find a Provider in the top menu bar and then select Network
Pharmacies under HealthChoice Provider Listings. You can also contact Medco, 24 hours
a day, 7 days a week, at:
With Part D call toll-free 1-800-590-6828 or toll-free TDD 1-800-716-3231
Without Part D call toll-free 1-800-903-8113 or toll-free TDD 1-800-825-1230
In certain instances, HealthChoice pays for your prescriptions when they are filled at
a non-Network pharmacy; however, a reduced benefit may apply. See Non-Network
Pharmacies later in this section.
Mail Service Pharmacy
Currently, Medicare members who live outside Oklahoma have the option to fill their
prescriptions through Medco's mail service pharmacy; however, effective March 2012,
Medicare members who live in Oklahoma can fill their medications through Medco's mail
service pharmacy. If you would like to fill your prescriptions through the mail service
pharmacy, contact Medco and they will send you the materials you will need to use this
new service. Please contact Medco at:
With Part D call toll-free 1-800-590-6828 or toll-free TDD 1-800-716-3231
Without Part D call toll-free 1-800-903-8113 or toll-free TDD 1-800-825-1230
Pharmacy Benefit Information
The HealthChoice Medicare Formulary
HealthChoice has a list of covered medications, known as the HealthChoice Medicare
Formulary. This list tells which drugs are covered, which drug tier they are in, and if
there are any restrictions that apply.
This formulary was designed with a team of doctors and pharmacists and lists the
categories of drugs believed to be part of a good prescription drug program. Medicare has
approved this formulary. If you were Medicare eligible during the annual Option Period,
a copy of the HealthChoice Medicare Formulary was included in your Option Period
enrollment materials.
The formulary is available on the HealthChoice website at www.sib.ok.gov or www.
healthchoiceok.com. To request a printed copy, contact HealthChoice Member Services,
Monday through Friday, 7:30 a.m. to 4:30 p.m., Central time, at:
With Part D call 1-405-717-8699 or toll-free 1-800-865-5142
Without Part D call 1-405-717-8780 or toll-free 1-800-752-9475
TDD users call 1-405-949-2281 or toll-free 1-866-447-0436
The formulary lists Preferred and non-Preferred drugs. While most generics are
Preferred, some brand-name medications are also Preferred. Generally, HealthChoice
does not cover brand-name drugs when generics are available. Generic drugs have
the same active ingredients as brand-name drugs and are rated by the Food and Drug
Administration (FDA) to be as safe and effective as brand-name drugs. Generics usually
cost less than brand-name drugs. For more information, visit www.sib.ok.gov or www.
healthchoiceok.com or contact Medco, 24 hours a day, 7 days a week, at:
With Part D call toll-free 1-800-590-6828 or toll-free TDD 1-800-716-3231
Without Part D call toll-free 1-800-903-8113 or toll-free TDD 1-800-825-1230
Changes to the Formulary During the Year
Most formulary changes occur at the beginning of each plan year; however, sometimes
formulary changes occur midyear. HealthChoice may:
Add or remove a drug from the formulary
Add or remove a coverage restriction
Replace a brand-name drug with a generic
Move a drug to a higher or lower tier
If a drug you take is affected by a change, HealthChoice is required to notify you at least
60 days before the change, or at the time you request a refill. If you receive notice of
26 Pharmacy Benefit Information
27
a formulary change, work with your physician to switch your prescription to a covered
drug. Depending on the type of change, you may be able to request a prior authorization
and ask HealthChoice to continue to cover the drug for you.
If the Food and Drug Administration finds a drug is unsafe or a drug is removed from the
market, HealthChoice will immediately remove the drug from our formulary and then
notify you of the change. Your doctor will also know about this change and can prescribe
another drug for your condition.
Using the HealthChoice Medicare Formulary
Brand-name and generic medications are listed in the formulary by the general medical
condition they treat and also alphabetically at the back of the formulary. Brand-name
medications appear in all capital letters (LIPITOR) and generic medications are listed
in lower-case italics (atorvastatin). Listed by each drug name is the drug tier and a code
indicating restrictions, if applicable. See Some Drugs Have Restrictions in this section.
Drug Tiers
HealthChoice has a five-tier drug formulary, and in general, each tier represents a different
cost group. Tier 1 medications usually have the lowest out-of-pocket costs, and Tier 3
drugs have the highest out-of-pocket costs. If a generic drug is not available, a Tier 2 drug
is your next least expensive choice. Drug tiers are as follows:
Tier 1 – Generic medications
Tier 2 – Preferred, brand-name medications
Tier 3 – Non-Preferred, brand-name medications
Tier 4 – Preferred, very high cost, and unique formulary drugs
Tier 5 – Preferred tobacco cessation medications with a $0 copay
Medically Necessary Drugs
Your prescription drugs must be deemed reasonable and necessary for the treatment
of your illness or injury. They must also be deemed the accepted treatment for your
condition.
Drugs Covered Under Medicare Part A and Part B
Medicare Part A and Part B provide coverage for some medications. Your HealthChoice
coverage does not affect drugs that are covered under Medicare Part A or Part B.
Pharmacy Benefit Information
28
Medicare Part A covers drugs you receive during Medicare-covered stays in a
hospital or a skilled nursing facility
Medicare Part B covers certain chemotherapy drugs and certain drug injections you
receive in an office visit setting or given at a dialysis facility
Not All Drugs are Covered
Not all prescription drugs are covered. The law does not allow Medicare to cover
certain types of drugs, and HealthChoice decided not to cover certain drugs.
Some Drugs Have Restrictions
Some drugs have additional requirements or coverage limits. If there is a restriction on
a drug you are taking, your provider must take extra steps in order for HealthChoice to
cover your drug.
1. Prior Authorization (PA)
Prior authorization is required before HealthChoice will cover certain drugs, even though
they are listed in the HealthChoice Medicare Formulary. It is required when the drug:
yyHas a very high cost yyMight be covered under Medicare Part B
yyHas specific prescribing guidelines yyIs generally used for cosmetic purposes
See Medications Requiring Prior Authorization (PA) later in this section.
2. Quantity Limits (QL)
Due to approved therapy guidelines, certain drugs have quantity limits. Quantity limits
can apply to the number of refills you are allowed, or how much of the drug you can
receive per fill. Quantity Limits also apply if the medication form is other than a tablet or
capsule. See Medications Subject to Quantity Limits (QL) later in this section.
3. Limited Availability (LA)
Certain drugs are available at only certain pharmacies. For more information, contact
Medco, 24 hours a day, 7 days a week, at:
With Part D call toll-free 1-800-590-6828 or toll-free TDD 1-800-716-3231
Without Part D call toll-free 1-800-903-8113 or toll-free TDD 1-800-825-1230
Pharmacy Benefit Information
29
4. Enhanced Drug (ED)
These drugs are not normally covered, but HealthChoice has elected to cover them. The
amounts you pay for these drugs do not count toward your total drug costs. If you receive
Extra Help paying for your prescriptions, you will not receive help paying for an ED drug.
5. Part B versus Part D Drug (B/D)
These drugs may be covered by Medicare Part B or Part D depending on the situation.
Prior authorization is required to determine how the drug must be billed. Your physician
must provide information about the use and the place the drug is administered.
6. Step Therapy (ST)
Step Therapy requires you to first try a less costly drug to treat your medical condition
before HealthChoice covers another drug for that same condition. For example, drug A and
B both treat the same medical condition. You must first try drug A, and if it does not work
for you, HealthChoice will cover drug B.
Requesting a Pharmacy Prior Authorization
A request for prior authorization must be submitted by your physician. Your request must
be approved before you fill your prescription. To apply:
1. Have your physician’s office contact Medco toll-free at 1-800-753-2851.
2. Medco will fax a Prior Authorization Form to your physician’s office and request
that it be completed and faxed back.
3. If your prior authorization is approved, your physician’s office is notified of the
approval within 24 to 48 hours. You are also notified in writing.
4. If your prior authorization is denied, your physician’s office is notified of denial
within 24 to 48 hours. You are also notified in writing.
Note: In most cases, a prior authorization is valid for one year from the date it is
issued and must be renewed when it expires. For a list of medications that require prior
authorization, see Medications Requiring Prior Authorization (PA) later in this section.
Non-Preferred Prior Authorization (High Option Plans)
If you choose a non-Preferred drug when a Preferred drug is available, you must pay the
non-Preferred copay, unless you get a Tier Exception for a lower copay. Specific medical
guidelines must be met and information must be supplied by your physician to justify your
request. Your physician can contact Medco, 24 hours a day, 7 days a week, at:
Pharmacy Benefit Information
Toll-free 1-800-841-5409 or toll-free TDD 1-800-871-7138
Non-Formulary Medication Prior Authorization
If you are prescribed a medication that is non-formulary, you can:
1. Ask your physician for a prescription for a generic (Tier 1) or Preferred (Tier 2)
medication that is on the HealthChoice Medicare Formulary.
2. Continue the non-covered/non-formulary medication and pay the full cost.
3. Request a prior authorization to receive the medication at the non-Preferred copay.
For more information, contact HealthChoice Member Services, Monday through
Friday, 7:30 a.m. to 4:30 p.m., Central time, at:
With Part D call 1-405-717-8699 or toll-free 1-800-865-5142
Without Part D call 1-405-717-8780 or toll-free 1-800-752-9475
TDD users call 1-405-949-2281 or toll-free 1-866-447-0436
Transition Supply of Medication (Plans with Part D)
A transition supply of medication is a temporary, 34-day supply that is made available to
provide enough time for you to make a transition to a formulary drug or to request a prior
authorization. This one-time supply is available when:
You enroll in a Medicare supplement plan
Your physician writes a new prescription for a drug that is non-formulary
Your newly prescribed medication requires a prior authorization or has quantity
limits
Your medication is no longer covered
You enter or leave a hospital or other setting such as a long-term care facility
Other situations may qualify for a transition supply, and under some circumstances, this
34-day supply can be extended. In rare instances, such as when a medication is excluded
or when a medication is covered under Part B, a transition supply is not available.
For more information on how to obtain a covered transition supply of medication, have
your pharmacy contact Medco at the Pharmacy Help Line 24 hours a day, 7 days a week
including holidays, at:
Toll-free 1-800-922-1557 or toll-free TTY/TDD 1-800-825-1230
30 Pharmacy Benefit Information
Medication Quantities
Pharmacy benefits generally cover up to a 34-day supply or 100 units (tablets or
capsules), whichever is greater. Quantities cannot exceed the FDA approved ‘usual’
dosing recommendations. Some drugs have more restrictive quantity and/or length of
therapy limits. Quantities are subject to your doctor’s written orders.
Specialty Medications
Specialty medications are usually high-cost, injectable medications that require special
handling.
Plans With Part D
You must purchase your specialty medications from a Network pharmacy. Your costs for
Preferred medications are as follows:
yyIf the cost of the medication is $100 or less, you pay up to a $30 copay or the
cost of medication, if less
yyIf the cost of the medication is more than $100 you pay 25% up to a $60
maximum copay
For more information, see the pharmacy benefit charts earlier in this section.
Plans Without Part D
You must purchase your specialty medications from the HealthChoice specialized
pharmacy, Accredo Health. You pay the applicable copay for each 30-day fill. Accredo
provides free supplies, such as needles and syringes, free shipping, refill reminder calls,
and personal counseling with a registered nurse or pharmacist. If you don’t order your
specialty medications through Accredo, you must pay the full cost. Your costs are:
yyPreferred medications – $60 copay for each 30-day supply
yyNon-Preferred medications – $120 copay for each 30-day supply
For more information, contact Accredo:
Toll-free 1-800-501-7260 or toll-free TDD 1-800-759-1089
Tobacco Cessation Products
HealthChoice covers two, 90-day courses of the following tobacco cessation medications
31
Pharmacy Benefit Information
for a $0 copay when they are purchased at a Network Pharmacy:
Buproban 150mg Tabs Nicotrol NS 20mg/m Nasal Spray
Bupropion HCL SR 150mg Tabs Nicotrol 10mg Cartridge
Chantix 0.5mg and 1mg Tabs
Additionally, HealthChoice partners with the Oklahoma Tobacco Settlement Endowment
Trust (TSET) and Alere Wellbeing to provide over-the-counter nicotine replacement
therapy products (patches, gum, and lozenges) and telephone coaching at no charge. To
take advantage of these benefits, contact the Oklahoma Tobacco Helpline at 1-800-QUIT-NOW
(1-800-784-8669) and identify yourself as a HealthChoice member. The Helpline
hours of operation are 7 a.m. to 2 a.m. seven days a week. Members living outside
Oklahoma call 1-866-QUIT-4-LIFE (1-866-784-8454).
Vaccines Covered Under Your Pharmacy Benefits
The rules for coverage of vaccinations are complicated. If you have a question about how
a particular vaccine is covered, contact Medco, 24 hours a day, seven days a week, at:
With Part D call toll-free 1-800-590-6828 or toll-free TDD 1-800-716-3231
Without Part D call toll-free 1-800-903-8113 or toll-free TDD 1-800-825-1230
The coverage of vaccinations includes two parts – the cost of the medication itself and
the cost of giving the vaccination shot. What you pay for a Part D covered vaccination
depends on three things:
1. The type of vaccine – some vaccines are covered under Medicare Part D, while
others are covered under original Medicare
2. Where you get the vaccine medication
3. Who gives you the vaccination shot
Plans With Part D
yyIf the vaccine is purchased through and administered by a pharmacist who
is certified to give vaccines, the pharmacy electronically submits a claim
for the vaccine and the administration fee. You are responsible for the
appropriate copay.
yyIf you purchase the vaccine from your pharmacy and take it to your
physician’s office for administration, your pharmacy electronically submits
a claim for the vaccine medication, but you have to file a paper claim with
Medco for reimbursement of the administration fee.
32 Pharmacy Benefit Information
yyIf you get a Part D vaccine at your doctor's office, you must pay the entire
cost of the vaccine and its administration. You can then file a paper claim
for reimbursement of the vaccine and the administration fee, minus the
appropriate copay.
Plans Without Part D
yyYou are responsible for administration fees for vaccines covered under
pharmacy benefits.
When You are Hospitalized
If you are admitted to a hospital for a Medicare-covered stay, Part A should cover
your prescription drug costs. Once you leave the hospital, HealthChoice covers your
prescription drugs as long as they meet the rules for coverage. HealthChoice also covers
your drugs if they are approved through a coverage determination, exception, or appeal.
When You are Admitted to a Skilled Nursing Facility
If you are admitted to a skilled nursing facility for a Medicare-covered stay, after
Medicare Part A stops paying for your prescriptions, HealthChoice covers them as long as
they meet the rules for coverage. The facility must be a HealthChoice Network Pharmacy,
and the drug cannot be covered under Part B. HealthChoice also covers your drugs if they
are approved through a coverage determination, exception, or appeal.
When You Live in a Long-term Care Facility
Usually, a long-term care facility, such as a nursing home, has its own pharmacy, or a
pharmacy that supplies drugs to its residents. If you reside in a long-term care facility, you
can get your drugs through the facility's pharmacy as long as they are part of the pharmacy
network.
Accessing Part D Medications During a
Declared National Disaster or Public Health Emergency
Members with Part D can replace lost or damaged medications if the loss occurred as the
result of a declared national disaster or public health emergency. Your pharmacy must
contact Medco's Pharmacy Help Line toll-free at 1-800-922-1557. Medco will work with
your pharmacy to authorize early refills or override the maximum days' supply per fill.
You must still pay the applicable copay per fill.
Pharmacy Benefit Information
33
Drug Safety Programs
Medco conducts drug reviews to make sure members receive safe and appropriate
prescription therapies. These reviews can be very important to those who have more
than one provider prescribing medications. Each time you fill a prescription, a review is
conducted to look for possible problems such as:
Medication errors
Dosage errors
Drugs that are not necessary because you take another drug for the same condition
Drugs that may be unsafe or inappropriate because of your age or gender
Combinations of drugs that could harm you if taken at the same time
Drugs you are allergic to
If any possible problems are detected, Medco notifies your pharmacist at the time your
prescription is filled.
Medication Therapy Management (Plans with Part D)
Medication Therapy Management (MTM) is a free program for members who suffer
from multiple, chronic health conditions and are being treated with multiple medications.
To be eligible, you must be expected to incur prescription drug costs that exceed $3,100
annually.
If you qualify, you are automatically enrolled in the program and will receive a letter
from Medco. The letter includes information about the program and a toll-free number
you can call to speak with a Medco pharmacist. Medco’s pharmacists are specially
trained in patient counseling and are prepared to discuss such topics as medication use
and compliance, drug education, health and safety, and cost saving measures. While the
program is voluntary, HealthChoice encourages eligible members to participate.
If you do not wish to participate in the program, you can contact Medco. For more
information, contact Medco, 24 hours a day, 7 days a week, at:
Toll-free 1-800-590-6828 or toll-free TDD 1-800-716-3231
Non-Network Pharmacies
Although HealthChoice may cover your prescriptions when they are purchased at a non-
Network pharmacy, a reduced benefit applies. An exception can be made in the event of
an emergency. It is considered an emergency when you:
Travel outside the HealthChoice service area and run out of medication, or become
34 Pharmacy Benefit Information
ill and need a covered medication and are unable to access a Network Pharmacy
Cannot timely get a covered medication within your plan’s pharmacy network
Fill a prescription for a medication that is not stocked at a Network Pharmacy
Receive a prescription for a covered medication that is dispensed by a non-
Network outpatient facility, such as an emergency room, clinic, or surgery center
If you must use a non-Network pharmacy, you must pay the full cost for your medication
and then ask HealthChoice to repay you for its share of the cost. See the Claim
Procedures section. Before you fill a prescription in this situation, check to see if there is
a Network Pharmacy in your area. See the HealthChoice website at www.sib.ok.gov or
www.healthchoiceok.com. You can also contact Medco, 24 hours a day, 7 days a week
at:
With Part D call toll-free 1-800-590-6828 or toll-free TDD 1-800-716-3231
Without Part D call toll-free 1-800-903-8113 or toll-free TDD 1-800-825-1230
Pharmacy Explanation of Benefits (EOB)
A pharmacy EOB gives the total amount you have spent on your prescription drugs and
the total amount the plan has paid for your prescription drugs. This report is to help you
track your prescription drugs costs. HealthChoice is not required to send you a pharmacy
EOB, but you can request one by calling Medco, 24 hours a day, 7 days a week, at:
With Part D call toll-free 1-800-590-6828 or toll-free TDD 1-800-716-3231
Without Part D call toll-free 1-800-903-8113 or toll-free TDD 1-800-825-1230
Creditable Prescription Drug Coverage
HealthChoice Medicare Supplement Plans With and Without Part D provide Creditable
Coverage. Prescription drug coverage is called creditable if it meets or exceeds
Medicare’s prescription drug coverage guidelines. The HealthChoice Plans provide
coverage equal to (Low Option Plans) or better than (High Option Plans) the standard
benefits set by Medicare. HealthChoice is not required to send you a Creditable Coverage
letter, but if you need one, it is available on the HealthChoice website at www.sib.ok.gov
or www.healthchoiceok.com. Click the Members tab in the top menu bar and then select
Medicare Members. You can also request one by contacting HealthChoice Member
Services, Monday through Friday, 7:30 a.m. to 4:30 p.m., Central time, at:
With Part D call 1-405-717-8699 or toll-free 1-800-865-5142
Without Part D call 1-405-717-8780 or toll-free 1-800-752-9475
TDD users call 1-405-949-2281 or toll-free 1-866-447-0436
35
Pharmacy Benefit Information
What Types of Drugs Are NOT Covered
If you take a drug that is excluded from coverage, you must pay for that drug yourself.
Generally, HealthChoice cannot cover drugs that are:
1. Covered under Medicare Part A or Part B
2. Purchased outside the United States
3. Prescribed for off-label use – this means any use of a drug other than those indicated
on the drug's label
Also, by law, the following drug categories are excluded from coverage:
Most barbiturates and benzodiazepines Fertility drugs
Cough and cold medications Lost, stolen, or damaged medications**
Over-the-counter drugs Drugs not approved by the FDA
Drugs used for the treatment of anorexia,
weight loss, or weight gain
Drugs used for cosmetic purposes or
hair regrowth
Brand-name drugs from manufacturers
that do not participate in the Coverage
Gap Discount Program
All over-the-counter and prescription
vitamins – except prenatal vitamins
Impotency medications such as Cialis,
Levitra, Viagra, and Caverject*
If you receive Extra Help from Medicare to pay for your prescriptions, the Extra Help
program does not pay for drugs that are excluded from coverage. Additionally, any
amounts you pay for excluded drugs do not count toward your total drug costs.
*These drugs are specifically excluded from coverage unless you have had radical
retropubic prostatectomy surgery or certain other medical conditions. Prior authorization is
required.
**Part D covers medications lost or damaged as the direct result of a declared national
disaster or public health emergency.
36 Pharmacy Benefit Information
37
Adrenal Hormone Drugs a-methapred (injection solution reconstituted)
DEPO-MEDROL (injection suspension)
methylprednisolone (oral tablet)
methylprednisolone acetate (injection suspension)
methylprednisolone sodiumsuccinate (injection
solution reconstituted)
prednisolone sodium phosphate (oral solution)
prednisone (oral solution, oral tablet)
PREDNISONE INTENSOL (oral concentrate)
SOLU-MEDROL (injection solution reconstituted)
Anti-Hypertensive Drugs REMODULIN (injection solution)
Anti-Infective Drugs amphotericin b (injection solution reconstituted)
CUBICIN (injection solution reconstituted)
foscarnet sodium (injection solution)
NEBUPENT (inhalation solution reconstituted)
TOBI (inhalation nebulization solution)
vancomycin hcl (injection solution)
Anti-Neoplastic and
Immunosuppressant Drugs
AFINITOR (oral tablet)
azathioprine (oral tablet)
azathioprine sodium (injection solution
reconstituted)
CELLCEPT (oral capsule, oral suspension
reconstituted, oral tablet)
cyclophosphamide (oral tablet)
cyclosporine (oral capsule, injection solution)
cyclosporine modified (oral capsule, oral solution)
gengraf (oral capsule, oral solution)
methotrexate (oral tablet)
mycophenolate mofetil (oral capsule, oral tablet)
MYFORTIC (oral tablet delayed release)
NEORAL (oral capsule, oral solution)
NEXAVAR (oral tablet)
PROGRAF (oral capsule, injection solution)
RAPAMUNE (oral solution, oral tablet)
RHEUMATREX (oral tablet)
RITUXAN (concentrate)
Medications Requiring Prior Authorization (PA)
This List Includes Only Formulary Medications and is Subject to Change
Note: In most instances, new and generic equivalent medications that become available in
the drug categories listed below will automatically require prior authorization. New drug
categories may be added throughout the year.
Pharmacy Benefit Information
Generics are in lower case italics – Brand-names are in all capital letters
38
Anti-Neoplastic and
Immunosuppressant Drugs,
continued
SANDIMMUNE (oral capsule, injection solution,
oral solution)
SUTENT (oral capsule)
tacrolimus (oral capsule)
TARCEVA (oral tablet)
THALOMID (oral capsule)
TORISEL (injection solution)
ZORTRESS (oral tablet)
Cardiovascular, Hypertension,
and Lipid Drugs
nitroglycerin (injection solution)
Erectile Dysfunction Drugs
These medications are specifically
excluded from coverage unless
you have had radical retropubic
prostatectomy surgery.
CAVERJECT (injection solution)
CIALIS (oral tablet)
LEVITRA (oral tablet)
MUSE (oral tablet)
VIAGRA (oral tablet)
Gastroenterology Drugs CIMZIA (kit)
dronabinol (oral capsule)
EMEND (oral capsule)
granisetron (oral tablet)
ondansetron hcl (oral solution, oral tablet)
ondansetron odt (oral tablet dispersible)
REMICADE (injection solution)
ZUPLENZ (film)
Immunology, Vaccines, and
Biotechnology Drugs
ARANESP (injection solution)
AVONEX (kit)
BETASERON (injection solution reconstituted)
ENERIX-B (injection suspension)
EPOGEN (injection solution)
HIZENTRA (injection solution)
LEUKINE (injection solution reconstituted)
NEULASTA (injection solution)
NEUMEGA (injection solution reconstituted)
NEUPOGEN (injection solution)
NORDITROPIN FLEXPRO (injection solution)
NORDITROPIN NORDIFLEX PEN (injection
solution)
OMNITROPE (injection solution)
PRIVIGEN (injection solution)
PROCRIT (injection solution)
REBIF (injection solution)
REBIF TITRATION PACK (injection solution)
RECOMBIVAX HB (injection suspension)
TEV-TROPIN (injection solution reconstituted)
Pharmacy Benefit Information
39
Immunology, Vaccines, and
Biotechnology Drugs
TWINRIX (injection suspension)
VIVAGLOBIN (injection solution)
Miscellaneous Agents levocarnitine (solution, oral tablet)
Miscellaneous Hormones ALDURAZYME (injection solution)
ANADROL-50 (oral tablet)
ANDRODERM (oral tablet)
ANDROGEL (topical gel)
ANDROID (oral capsule)
androxy (oral tablet)
calcitriol (oral capsule, solution)
CEREZYME (injection solution reconstituted)
FABRAZYME (injection solution reconstituted)
SOMAVERT (injection solution reconstituted)
testosterone cypionate (oil)
testosterone enanthate (oil)
ZEMPLAR (oral capsule, injection solution)
Miscellaneous Neurological
Drugs
COPAXONE (kit)
GILENYA (oral capsule)
Non-Narcotic Analgesic Drugs CELEBREX (oral capsule)
Osteoporosis Drugs BONIVA (oral tablet)
Psychotherapeutic Drugs dextroamphetamine sulfate (oral tablet)
dextroamphetamine sulfate er (oral capsule)
FOCALIN XR (oral capsule)
METADATE CD (oral capsule)
methylphenidate hcl (oral tablet)
methylphenidate hcl sr (oral tablet)
PROVIGIL (oral tablet)
RITALIN LA (oral capsule)
Pulmonary Drugs acetylcysteine (inhalation solution)
albuterol sulfate (inhalation nebulization solution)
budesonide (inhalation solution)
cromolyn sodium (inhalation nebulization solution)
ipratropium bromide (inhalation solution)
ipratropium bromide/albuterol sulfate (inhalation
solution)
PERFOROMIST (inhalation solution)
PULMICORT (inhalation suspension)
PULMOZYME (inhalation solution)
XOLAIR (injection solution reconstituted)
Rheumatologic Drugs ENBREL (injection solution)
HUMIRA (kit)
SIMPONI (injection solution)
Pharmacy Benefit Information
40 Pharmacy Benefit Information
Medications Subject to Quantity Limits (QL)
This List Includes Only Formulary Medications and is Subject to Change
Note: Non-formulary medications that are approved for coverage by a prior authorization
can also be limited in quantity. In most instances, new medications and generic equivalent
medications that become available in the drug categories listed below will automatically
have quantity limits. New drug categories may be added throughout the year.
Anticholinergic and Antispasmodic
Drugs
OXYTROL (transdermal biweekly patch)
Antineoplastic and
Immunosuppressant Drugs
AFFINITOR (oral tablet)
NEXAVAR (oral tablet)
REVLIMID (oral capsule)
SPRYCEL (oral tablet)
SUTENT (oral capsule)
TARCEVA (oral tablet)
TASIGNA (oral capsule)
TYKERB (oral tablet)
VANDETANIB (oral tablet)
VIDAZA (injection suspension)
VOTRIENT (oral tablet)
ZOLINZA (oral capsule)
ZYTIGA (oral tablet)
Antiviral Drugs RELENZA DISKHALER (blister inhalation
aerosol powder breath activated)
TAMIFLU (oral capsule)
Diabetic Drugs and Supplies All BD insulin syringes
All insulins: APIDRA, BYETTA,
HUMALOG, HUMULIN, LANTUS,
LEVEMIR, NOVOLIN, NOVOLOG,
SYMLIN
Diagnostic and Miscellaneous Drugs alendronate sodium (40mg oral tablet)
Erectile Dysfunction Drugs:
These medications are specifically
excluded from coverage unless
you have had radical retropubic
prostatectomy surgery.
CAVERJECT (injection solution
reconstituted)
CAVERJECT IMPULSE (injection solution
reconstituted)
CIALIS (oral tablet)
LEVITRA (oral tablet)
MUSE (oral tablet)
VIAGRA (oral tablet)
Estrogen and Progestin Therapy
Drugs
ALORA (biweekly transdermal patch)
CLIMARA PRO (transdermal weekly patch)
COMBIPATCH (transdermal biweekly patch)
DIVIGEL (transdermal gel)
ESTRADERM (transdermal biweekly patch)
estradiol (transdermal weekly patch)
MENOSTAR (transdermal weekly patch)
VIVELLE-DOT (transdermal biweekly patch)
Migraine Therapy Drugs butorphanol tartrate (nasal solution)
MAXALT (oral tablet)
MAXALT-MLT (oral dispersible tablet)
MIGRANAL (nasal solution)
naratriptan hcl (oral tablet)
RELPAX (oral tablet)
sumatriptan succinate (injection solution, oral
tablet)
ZOMIG (nasal solution, oral tablet)
ZOMIG ZMT (oral dispersible tablet)
Miscellaneous Gastrointestinal Drugs CIMZIA (injection kit)
EMEND (oral capsule)
ondansetron hcl (oral tablet)
ondansetron odt (oral dispersible tablet)
SANCUSO (transdermal patch)
ZUPLENZ (film)
Miscellaneous Hormones ANDRODERM (transdermal patch)
ANDROGEL (transdermal patch gel)
calcitonin-salmon (nasal solution)
fortical (nasal solution)
SOMAVERT (injection solution reconstituted)
Miscellaneous Neurological Drugs COPAXONE (injection kit)
GILENYA (oral capsule)
Multiple Sclerosis Therapy Drugs AVONEX (injection kit, vial)
BETASERON (injection solution
reconstituted)
REBIF (injection solution)
Narcotic Analgesic Drugs fentanyl (transdermal 72-hour patch)
Non-Narcotic Analgesic Drugs butorphanol tartrate (nasal solution)
41
Pharmacy Benefit Information
42 Pharmacy Benefit Information
Opthalmic Therapy Drugs RESTASIS (ophthalmic emulsion)
Osteoporosis Therapy Drugs alendronate sodium (oral tablet)
BONIVA (oral tablet)
FORTEO (injection solution)
Psychotherapeutic Drugs EMSAM (transdermal 24-hour patch)
PROVIGIL (oral tablet)
zaleplon (oral capsule)
zolpidem tartrate (oral tablet)
zolpidem tartrate er (oral tablet)
Pulmonary Drugs flunisolide (nasal solution)
fluticasone propionate (nasal suspension)
XOLAIR (injection solution)
Rheumatoid Arthritis Therapy
Drugs
ENBREL (injection kit)
ENBREL (injection solution)
ENBREL SURECLICK (injection solution)
HUMIRA (injection kit)
leflunomide (oral tablet)
SIMPONI (injection solution)
Tobacco Cessation Drugs buproban (oral tablet)
CHANTIX (oral tablet)
NICOTROL INHALER (inhaler)
NICOTROL NS (nasal solution)
Topical Anesthetic Drugs LIDODERM (external patch)
Claim Procedures
Deadline for Filing Claims
Claims must be received by HealthChoice no later than December 31 of the year
following the year claims were incurred. For example, if the date of service was July 1,
2011, the claim is accepted through December 31, 2012.
Filing a Health Claim
Most providers file your claims with Medicare and then automatically file your claims
with HealthChoice. To process your claim electronically, HealthChoice must have your
and your covered dependents’ Medicare numbers on file.
If you have to file your claim with HealthChoice yourself, you must wait until Medicare
sends you an Explanation of Benefits statement for Part A and Part B services. You can file
your claim with HealthChoice by sending a copy of the Explanation of Benefits statement
to:
HP Administrative Services, LLC
P.O. Box 24870
Oklahoma City, OK 73124-0870
Coordination of Health Benefits
If you or your covered dependents have claims that are covered by another group health
plan, HealthChoice benefits are coordinated with your other plan so that total benefits are
not more than the amount billed or your liability. If your other group coverage is primary
over your HealthChoice coverage, you must file claims with your primary plan first. If
your other group coverage terminates, please send written notice to:
HP Administrative Services, LLC
P.O. Box 24870
Oklahoma City, OK 73124-0870
If you have questions about coordination of benefits, please contact HP Administrative
Services, LLC, Monday through Friday, 7:30 a.m. to 6:00 p.m., Central time, at:
1-405-416-1800 or toll-free 1-800-782-5218
TDD users call 1-405-416-1525 or toll-free 1-800-941-2160
43
Claim Procedures
44
Medicare Beneficiaries with End-Stage Renal Disease
If you have End-Stage Renal Disease, Medicare is the secondary payer to your
employer’s group health plan for 30 months. This rule applies regardless of whether you
are a primary member or covered as a dependent under a group health plan. During this
30-month time period, group health plans always pay first.
If you have questions about coverage of End-Stage Renal Disease, visit Medicare's
website at www.medicare.gov or call Medicare, 24 hours a day, 7 days a week, at:
Toll-free 1-800-MEDICARE (1-800-633-4227)
Toll-free TTY/TDD 1-877-486-2048
Filing a Pharmacy Claim
Usually, your claim is processed electronically at the pharmacy. If your pharmacy has
questions, have them contact the Medco Pharmacy Help Line, 24 hours a day, 7 days a
week including holidays, at:
Toll-free 1-800-922-1557 or toll-free TTY/TDD 1-800-825-1230
In some cases, you may need to pay the full cost of your drug and then ask HealthChoice
to repay you for its share. You may need to ask for reimbursement when:
You use a non-Network pharmacy
You pay the full cost for a drug because you did not have your plan ID card
Your drug has a restriction and you decide to purchase the drug immediately
To ask for reimbursement, send your pharmacy receipt and Coordination of Benefits/
Direct Claim Form to:
With Part D – Medco, P.O. Box 14718, Lexington, KY 40512
Without Part D – Medco, P.O. Box 14711, Lexington, KY 40512
While you don’t have to use a Coordination of Benefits/Direct Claim Form, it is helpful.
You can access a form on our website at www.sib.ok.gov or www.healthchoiceok.com
or by calling Medco, 24 hours a day, 7 days a week, at:
With Part D call toll-free 1-800-590-6828 or toll-free TDD 1-800-716-3231
Without Part D call toll-free 1-800-903-8113 or toll-free TDD 1-800-825-1230
If your claim involves other group health insurance, include a copy of the Explanation of
Claim Procedures
45
Benefits statement you received from your other plan. When your request for payment is
received, Medco will let you know if more information is needed to process your claim.
If your claim is for a covered medication and you followed all Plan guidelines,
HealthChoice reimburses you for its share of the cost.
If your claim is for a non-covered medication or you did not follow Plan guidelines,
HealthChoice sends you a letter letting you know the reasons for not sending
reimbursement and what your rights are to appeal the decision.
Coordination of Pharmacy Benefits
If you or a covered dependent have other group pharmacy coverage that is primary over
HealthChoice, your pharmacy can still process your prescription claims electronically at
the time of purchase. If your pharmacy can file claims electronically, show the pharmacist
your HealthChoice Prescription Drug ID card and your primary insurance ID card. If
the pharmacy cannot file your secondary HealthChoice claims electronically, have them
contact the Medco Pharmacy Help Line, 24 hours a day, 7 days a week, at:
Toll-free 1-800-922-1557 or toll-free TTY/TDD 1-800-825-1230
If you have to file a paper claim, see Filing a Pharmacy Claim in this section for
instructions. If you have questions about pharmacy coordination of benefits, please
contact Medco, 24 hours a day, 7 days a week, at:
With Part D call toll-free 1-800-590-6828 or toll-free TDD 1-800-716-3231
Without Part D call toll-free 1-800-903-8113 or toll-free TDD 1-800-825-1230
Claims for Services Outside the United States (see note next page)
When traveling outside the U.S. and its territories, you must pay for your medical
expenses and then ask HealthChoice to pay you back. Your itemized bill must be
translated to English and converted to U.S. dollars using the exchange rates applicable
for the dates of service. Medical claims must be submitted to:
HP Administrative Services, LLC, PO Box 24870, Oklahoma City, OK 73124-0870
For questions about claim filing, call HP Administrative Services, LLC, Monday through
Friday, 7:30 a.m. to 6:00 p.m., Central time, at:
1-405-416-1800 or toll-free 1-800-782-5218
TDD users call 1-405-416-1525 or toll-free 1-800-941-2160
Claim Procedures
46
Note: HealthChoice does not pay for medications purchased outside the United States.
Private Contracts with Physicians and Practitioners
A Private Contract is a written agreement between a Medicare beneficiary and a doctor
or practitioner who does not provide services through the Medicare program. These
providers have opted out of Medicare, and you must sign a Private Contract with them
before they will provide care. If you sign a Private Contract, be aware that:
Medicare’s limiting charge does not apply. You pay what the practitioner charges.
Claims for these services are not covered by Medicare or HealthChoice and neither
Medicare nor HealthChoice pay anything for these services.
Subrogation
Subrogation is a process that is followed when you become sick or injured as a
result of the negligent act or omission of another person or party. Subrogation means
HealthChoice has a right to recover any benefit payments made to you or your
dependents by a third party’s insurer, because of an injury or illness caused by the third
party. Third party means another person or organization.
If you or your covered dependents receive HealthChoice benefits and have a right to
recover payments from a third party, this Plan has the right to recover any benefits paid
on your behalf. All payments from a third party, whether by lawsuit, settlement, or
otherwise, must be used to repay HealthChoice for your health care costs.
You must promptly notify HealthChoice if you file a claim against a third party for any
illness or injury for which HealthChoice benefits have been or will be paid. You or your
dependent must provide all the information HealthChoice requests. HealthChoice benefits
can be withheld until information is received.
Once HealthChoice has the needed information, your covered claims are processed,
regardless of whether a third party is eventually found liable for your health care costs.
For more information about subrogation, please contact OSEEGIB, Monday through
Friday, 7:30 a.m. to 4:30 p.m., Central time, at:
1-405-717-8701 or toll-free 1-800-543-6044
TDD users call 1-405-949-2281 or toll-free 1-866-447-0436
Do not contact the claims office, HP Administrative Services, LLC, regarding
subrogation as this will only delay a response.
Claim Procedures
47
Eligibility,
Enrollment, and Disenrollment
Medicare Eligibility
Medicare is the federal health insurance program for people:
Age 65 and older
Under age 65 with qualified disabilities
With End-Stage Renal Disease
The Centers for Medicare and Medicaid Services (CMS) manage the Medicare program.
The Social Security Administration determines eligibility, enrolls people in Medicare,
and collects Medicare premiums. For information about Medicare, visit the CMS website
at www.cms.gov or the Social Security website at www.ssa.gov. You can also contact
Social Security, Monday through Friday, 7:00 a.m. to 7:00 p.m., Central time, at:
Toll-free 1-800-772-1213 or toll-free TTY/TDD 1-800-325-0778
Medicare is divided into several parts. The parts of Medicare that apply to your Plan
include:
Part A covers services provided by hospitals, skilled nursing facilities, or home
health agencies.
Part B covers most other medical services, such as physician's services, outpatient
services, and durable medical equipment and supplies.
Part D covers prescription drugs.
Enrollment in Medicare
Enrollment in Medicare is handled in two ways – either you are automatically enrolled or
you must apply.
If you receive Social Security or Railroad Retirement Board benefits before you turn 65,
you are automatically enrolled, and your Medicare ID card is mailed to you about three
months before your 65th birthday.
If you are not already receiving Social Security or Railroad Retirement Board retirement
benefits, you must apply for Medicare by contacting the Social Security Administration,
or if appropriate, the Railroad Retirement Board.
Eligibility, Enrollment, and Disenrollment
48
If you have been a disabled beneficiary under Social Security or Railroad Retirement for
24 months, you will automatically get a Medicare ID card in the mail.
When You Become Medicare Eligible
When you become Medicare eligible because you turned 65, you are automatically
enrolled in the corresponding Medicare Supplement Plan With Part D. For example, if
you are a HealthChoice High Option Plan member, you are moved to the High Option
Medicare Supplement Plan With Part D. HealthChoice must have Medicare numbers on
file for you and your covered dependents. To provide this information, send a copy of
your and your dependents’ Medicare ID cards to:
HealthChoice, 3545 NW 58 Street, Suite 110, Oklahoma City, OK 73112
If you become Medicare eligible before age 65 due to a disability, you must complete and
return an Application for Medicare Supplement With Part D to enroll. You are enrolled in
the Plan on the first day of the month following the receipt of your application or on the
effective date of Medicare coverage, whichever is later.
Eligibility Requirements
To enroll in a HealthChoice Medicare Supplement Plan, you must be:
Entitled to Medicare Part A and/or enrolled in Medicare Part B
Listed as eligible in Medicare's system
Reside in the United States or its territories
If you live abroad or you are in prison, you cannot enroll in a plan with Part D; however,
you can enroll in a plan without Part D.
Enrollment Periods
There are three time periods when you can enroll in or disenroll from HealthChoice.
The Initial Enrollment Period – The Initial Enrollment Period refers to the time
you are first eligible to enroll in Medicare. This seven-month period begins three
months before the month you become eligible and extends three months after
the month of your eligibility. For example, Mrs. Smith turns 65 on April 20 and
becomes eligible for Medicare Part A. Her Part B and Part D enrollment period
begins on January 1 and ends on July 31.
The Annual Enrollment Period/Option Period – Medicare has set the dates of
the Annual Enrollment Period/Option Period as October 15 through December 7 of
Eligibility, Enrollment, and Disenrollment
49
each year. The final deadline of December 7 is strictly enforced by Medicare. Once
the annual enrollment period ends, enrollments/disenrollments cannot be made
until the next annual Option Period.
Special Enrollment Periods – Special Enrollment Periods are allowed when:
yyYou enter or leave a skilled nurse facility
yyYou move outside the United States or its territories
yyThe Plans’ participation in the Part D program is terminated
yyYou lose Creditable Coverage for reasons other than failure to pay premiums
yyYou meet other exception rules as set out by CMS
yyYou gain or lose Extra Help
For information on Special Enrollment Periods, contact HealthChoice Member Services,
Monday through Friday, 7:30 a.m. to 4:30 p.m., Central time, at:
With Part D call 1-405-717-8699 or toll-free 1-800-865-5142
Without Part D call 1-405-717-8780 or toll-free 1-800-752-9475
TDD users call 1-405-949-2281 or toll-free 1-866-447-0436
Effective Date of Coverage
Initial Enrollment Period – Effective date is the first of the month you become
Medicare eligible, or the first of the month following the processing of your
application, whichever is later
Annual Enrollment Period/Option Period – Effective date is January 1
Special Enrollment Periods – Effective date always follows the processing of your
application and can never be before that date.
Confirmation Statements
Anytime a change is made to your coverage, you are mailed a Confirmation Statement
(CS). Your CS lists the coverage you are enrolled in, the effective date of coverage, and
the premium amounts. Review your CS as soon as you receive it so any errors can be
corrected as soon as possible.
Dependent Coverage
Dependents can be added to coverage only if one of the following conditions is met:
Your dependent was insured under another group health plan and lost coverage
under that plan. Application for enrollment and proof of the termination of other
group health coverage must be submitted within 30 days of the loss. You must
cover all eligible dependents. Some exceptions apply. See Excluding Dependents
Eligibility, Enrollment, and Disenrollment
50
from Coverage in this section.
You marry and want to add your new spouse and dependent children to your
coverage. You must add them within 30 days of your marriage.
You gain a new dependent through birth, adoption, or legal guardianship. You must
add them within 30 days of the birth, adoption, or gaining legal guardianship.
COBRA continuation of coverage is available for dependents who lose eligibility. See
Consolidated Omnibus Budget Reconciliation Act (COBRA) in this section.
Eligible Dependents
Eligible dependents include:
Your legal spouse (including common-law)
Your daughter, son, stepdaughter, stepson, eligible foster child, adopted child or
child legally placed with you for adoption up to age 26, married or unmarried
A dependent, regardless of age, who is incapable of self-support due to a disability
that was diagnosed prior to age 26; subject to medical review and approval
Other unmarried dependent children up to age 26, upon completion of an
Application for Coverage for Other Dependent Children. Guardianship papers or a
tax return showing dependency may be provided in lieu of the application
You can only enroll dependents in the same type of coverage and in the same plans as
you. Dependents who are not enrolled within 30 days of your eligibility date cannot be
enrolled unless there is a qualifying event such as birth or marriage.
If you drop eligible dependents from coverage, you cannot re-enroll them unless they
lose other group coverage.
If your spouse is enrolled separately in a plan offered through OSEEGIB, your
dependents can be covered under only one parent’s health, dental, and/or vision plan (but
not both); however, both parents can cover dependents under Dependent Life insurance.
Newborn Limited Benefit – Newborns are covered for routine well-baby care for the
first 48 hours following a vaginal delivery or the first 96 hours following a C-section
delivery. Any additional services provided to your newborn that are considered non-routine
are not covered unless you enroll your newborn for the month of the birth and
pay the premium for that month. This means you are responsible for any charges over
and above the Plan's payment of the newborn limited benefit regardless of the facility's
Network or non-Network status. You have 30 days from the date of birth to enroll your
newborn in coverage. A separate calendar year deductible and coinsurance may apply
to the newborn depending on your plan. If you do not enroll your newborn during this
30-day time period, you cannot do so in the future. Your newborn's Social Security
Eligibility, Enrollment, and Disenrollment
number is not required at the time of initial enrollment, but must be provided when it is
received from the Social Security Administration. If you enroll your newborn, insurance
premiums must be paid for the full month of your child's birth.
Excluding Dependents from Coverage
Eligible dependents can be excluded from coverage if they have other group health
coverage or are eligible for Indian or military health benefits. You can exclude eligible
dependent children who do not live with you, are married, or are not financially
dependent on you for support. You can also exclude your spouse. You and your spouse
must both sign the Spouse Exclusion section of your Application for Retiree/Vested/Non-
Vest/Defer Insurance or the Spouse Exclusion section of your Option Period Enrollment/
Change Form if you drop your spouse during the Annual Enrollment Period/Option
Period.
To Request Coverage Changes
All requests for changes in coverage must be made in writing. Verbal requests for
changes are not accepted. Please send all requests for changes to:
HealthChoice
3545 NW 58 Street, Suite 110
Oklahoma City, OK 73112
or fax your request to 1-405-717-8939.
When Your Employer Changes Insurance Carriers
Education Retirees
If you were a career tech employee or a common school employee who terminated
employment on or after May 1, 1993, you can continue coverage through the Plan as
long as the school system from which you retired or vested continues to participate in
the Plan. If your school system terminates coverage with the Plan, you must follow your
former employer to its new insurance carrier.
If you were an employee of an education entity other than a common school (e.g.,
higher education, charter school, etc.), you can continue coverage through the Plan as
long as the education entity from which you retired or vested continues to participate in
the Plan. If your former employer terminates coverage with the Plan, you must follow
your former employer to its new insurance carrier.
51
Eligibility, Enrollment, and Disenrollment
Local Government Retirees
If you were a local government employee who terminated employment on or after
January 1, 2002, you can continue coverage through the Plan as long as the employer
from which you retired or vested continues to participate in the Plan. If your former
employer terminates coverage with the Plan, you must follow your former employer to its
new insurance carrier.
New Employer Retirees
All retirees of employers that joined the Plan after the grandfathered dates listed on the
previous page must follow their former employer to its new insurance carrier.
Following Your Employer to a New Plan
When you terminate employment, your benefits are tied to your most recent employer.
If that employer discontinues participation with OSEEGIB, some or all of their retirees
and dependents (depending on the type of employer) must follow the employer to its
new insurance carrier. This is true regardless of the amount of time you work for any
participating employer. If you retire and then return to work for another employer and
enroll in benefits through that employer, your benefits are tied to your new employer.
If You Return to Work
If you return to work and enroll in a group health plan offered through your employer,
that plan is your primary insurance carrier; however, you may be eligible to continue
your HealthChoice Medicare Supplement Plan as your secondary carrier.*
If you are able to opt out of your employer’s group health plan, Medicare is your primary
insurance carrier, and you may be eligible to continue your HealthChoice Medicare
Supplement Plan as your secondary carrier.*
If you are a retired or vested member returning to work and you did not continue health
coverage at the time you retired or vested, you must meet all the eligibility requirements
of a new employee.
*Be aware that your employer cannot provide a Medicare supplement plan, or pay for
any premiums related to a Medicare supplement plan.
Ending Your Coverage With HealthChoice
Ending your coverage with HealthChoice can be voluntary (your choice) or involuntary
52 Eligibility, Enrollment, and Disenrollment
(not your choice). You can choose to leave the Plan or HealthChoice may be required to
end your coverage.
If you terminate coverage in retirement or as a vested member, you cannot re-enroll in the
Plans offered through OSEEGIB.
If your dependent is dropped from your plan, they cannot be re-enrolled unless they lose
other group coverage.
You have the option to leave the Plan during the Annual Enrollment Period/Option
Period; however, in certain situations, you can leave the Plan at other times of the year,
known as Special Enrollment Periods.
As a retiree, if your health, dental, and/or life coverage is cancelled, it cannot be
reinstated at a later date unless you return to work as an employee of a participating
employer. You will forfeit any retirement system contribution paid toward your health
insurance premium. Vision coverage is not affected by the cancellation rule and can be
elected during the Annual Enrollment Period/Option Period as long as you keep one other
benefit through OSEEGIB.
If you are enrolled in a plan with Part D and you drop your HealthChoice coverage, you
must enroll in another Part D plan within 63 days to avoid a late enrollment penalty.
When HealthChoice Must End Your Coverage
HealthChoice must end your coverage in the Plan when:
You fail to pay premiums
You move out of the United States or its territories for more than 12 months
You go to prison
You lie about or withhold information about other prescription coverage you have*
You continuously behave in a way that is disruptive*
You allow someone else to use your ID card to purchase prescription drugs
*We cannot end your coverage for these reasons unless we first get permission from
Medicare. If HealthChoice ends your coverage, we send you a letter explaining our
reasons and include instructions about how you can file a complaint with the Plan.
In the Event of Your Death
Your surviving dependents can continue any coverage that was in effect at the time of
53
Eligibility, Enrollment, and Disenrollment
your death, as long as all premiums are paid. Surviving dependents have 60 days to notify
HealthChoice they wish to continue their coverage.
If your dependents are enrolled in a plan with Part D, their coverage is continued
automatically; however, they have the option to cancel coverage.
Coverage is retroactive to the first day of the month following your death. Surviving
dependents receive a bill for all past months’ premiums. Claims for medical treatment and
pharmacy purchases must be filed after your survivors are enrolled and premiums are
received.
Notice of your death should be directed to your retirement system and HealthChoice.
Consolidated Omnibus Budget Reconciliation Act (COBRA)
COBRA is federal legislation which gives members and their covered dependents who
lose health benefits the right to choose to continue group health benefits for limited
periods of time under certain circumstances. You and your covered dependents are
eligible to continue coverage for up to 18 months if you lose coverage due to:
A reduction in your hours of employment
Termination of your employment for reasons other than gross misconduct
Your covered spouse and dependent children are eligible to continue coverage for up to
36 months if coverage is lost for reasons such as:
A divorce or legal separation*
Your dependent loses eligibility
Your death (See In the Event of Your Death in this section)
As a former employee, you must notify OSEEGIB in writing within 30 days of a
divorce*, legal separation*, or your child’s loss of dependent status under this Plan.
You and/or your eligible dependents must elect continuation of coverage within 60 days
after the later of the following events occur:
The date the qualifying event would cause you or your dependents to lose coverage
The date OSEEGIB notifies you or your dependents of continuation of coverage
rights
It is the policy of OSEEGIB that for any benefit continued under COBRA, one person
must always pay the primary member premium. In cases where a spouse, child, or
children are insured under a particular benefit and the member did not keep coverage, one
54 Eligibility, Enrollment, and Disenrollment
person will always be billed at the primary member rate.
If you have questions about COBRA, contact HealthChoice Member Services, Monday
through Friday, 7:30 a.m. to 4:30 p.m., Central time, at:
1-405-717-8780 or toll-free 1-800-752-9475
TDD users call 1-405-949-2281 or toll-free 1-866-447-0436
*Oklahoma law prohibits dropping your spouse/dependents in anticipation of a divorce
or legal separation. If you are in the process of a divorce or legal separation, contact your
legal counsel for advice before making changes to your benefits coverage.
55
Eligibility, Enrollment, and Disenrollment
Your Responsibilities
The things you need to do as a HealthChoice member are listed below.
Get familiar with your benefits and the rules you must follow to get covered
services, supplies, and medications.
yyThis handbook provides the information you need to get covered services,
supplies, and medications. Please review it carefully.
Let HealthChoice know if you have other health or prescription drug coverage in
addition to your coverage through HealthChoice.
yyHealthChoice is required to follow rules set by Medicare to make sure
you are using all of your coverage in combination when you get covered
services, supplies, and medications. This is called coordination of benefits
because it involves coordinating benefits you receive from HealthChoice
with any other benefits available to you.
Tell your doctor and pharmacist you are a HealthChoice plan member.
yyShow your HealthChoice ID card to your doctor or pharmacist when you
receive services or medications. This helps to prevent fraud and protects
your benefits.
Help your doctors and other providers by giving them information, asking
questions, and following through on your treatment.
Pay what you owe.
Let HealthChoice know if you move.
yyIf you move outside the HealthChoice service area (the United States and its
territories), you cannot remain a member of the Plan with Part D.
yyIf you move within our service area, the United States and its territories, you
still need to let HealthChoice know so your member record can be updated.
If you have questions or concerns, contact HealthChoice Member Services, Monday
through Friday, 7:30 a.m. to 4:30 p.m., Central time, at:
With Part D call 1-405-717-8699 or toll-free 1-800-865-5142
Without Part D call 1-405-717-8780 or toll-free 1-800-752-9475
TDD users call 1-405-949-2281 or toll-free 1-866-447-0436
56 Your Responsibilities
Your Rights as a HealthChoice Member
Your Medicare prescription drug benefits and your rights and responsibilities are
governed by Oklahoma and federal laws. The primary federal law that applies to this
document is Title XVIII of the Social Security Act and the regulations created under
the Social Security Act by the Centers for Medicare and Medicaid Services (CMS). In
addition, other federal and state laws apply.
For more information about your rights, you can visit www.medicare.gov to read or print
the publication, Your Medicare Rights and Protections. You can also call Medicare, 24
hours a day, 7 days a week, at:
Toll-free 1-800-MEDICARE (1-800-633-4227)
Toll-free TTY/TDD 1-877-486-2048
You Can Make Complaints or ask the Plan to Reconsider Decisions
If you have problems or concerns about your covered services, the following Grievances
and Appeals section tells you what you can do. It gives details about how to deal with
problems and complaints. Regardless of whether you ask for a coverage decision, file an
appeal, or make a complaint, HealthChoice is required to treat you fairly.
Non-Discrimination
HealthChoice must obey laws that protect you from discrimination or unfair treatment.
OSEEGIB does not discriminate based on a person’s race, disability, religion, sex, sexual
orientation, health, ethnicity, creed, age, or national origin when it provides benefits.
Federal laws that prohibit discrimination include Title VI of the Civil Rights Act of
1964, the Rehabilitation Act of 1973, the Age Discrimination Act of 1975, the Americans
with Disabilities Act, and all other laws that apply to organizations that receive federal
funding.
If you want more information or have concerns about discrimination or unfair treatment,
please call the federal Office for Civil Rights at the following numbers:
Toll-free 1-800-368-1019 or toll-free TDD 1-800-537-7697
Timely Access to Covered Drugs
You have the right to get your prescriptions filled or refilled at any Network Pharmacy
57
Your Rights as a HealthChoice Member
without long delays. If you don’t think you are getting your Part D drugs in a reasonable
amount of time, see the Grievances and Appeals section. This section will explain how
you can file a grievance.
Protecting the Privacy of Your Personal Health Information
The laws that protect the privacy of your health information give you certain rights
related to getting information and controlling how your health information is used. Your
personal health information includes the personal information you gave HealthChoice
when you enrolled as well as your medical records and other medical and health
information.
Privacy Notice
This notice describes how medical information about you may be used and disclosed and
how you get access to this information. Please review this notice carefully.
OSEEGIB is a division of the Office of State Finance. OSEEGIB is a State of Oklahoma
governmental agency that is created and governed by Oklahoma law for the purpose
of administering health, life, disability, and dental benefits to state, local government,
and education employees, and other groups designated by statute, including each of the
preceding group’s respective retirees. Oklahoma privacy laws and the federal Health
Insurance Portability and Accountability Act (HIPAA) govern privacy matters between
OSEEGIB and its participants concerning the privacy of an individual member’s health
information. Information contained in an OSEEGIB member’s file is confidential by law
and we at OSEEGIB are committed to protecting the privacy and security of members’
information. This notice describes and gives you examples of how OSEEGIB will use
and disclose your health information and your rights regarding this information.
OSEEGIB uses and discloses your protected health information (PHI) for payment
of services to enable your medical treatment, and for OSEEGIB business operations
in the administration of health plans. The health claims you submit, or health claims
submitted by providers for your treatment, contain protected health information and are
processed for payment and data collection by claims administrators according to contract
terms with OSEEGIB. OSEEGIB and its claim administrators use and disclose your
PHI for payment responsibilities that include: collecting premiums, determination of
medical necessity according to certification procedures, eligibility issues, coordinating
benefits with other insurers, producing Explanations of Benefits, subrogation, and claim
adjudication. Contract terms with each of its claims administrators state that the claims
administrator is a Business Associate as defined in OSEEGIB Rules, with obligations
to protect members’ information. Your health information is used and disclosed by
OSEEGIB employees and other entities under contract with OSEEGIB according
58 Your Rights as a HealthChoice Member
to the “minimum necessary” standard. OSEEGIB or its claims administrators may
use and disclose health information for HealthChoice plan operations that include:
providing customer service, resolving grievances, conducting activities to improve
members health and reduce costs, case management and coordination of care, premium
rate setting activities, law enforcement, public health threats, workers’ compensation/
disability, national security, and as permitted or required by law. OSEEGIB provides
limited member information to participating plan sponsors for enrollment purposes and
premium comparison. OSEEGIB will ask for your written permission before it uses
or discloses your health information for purposes that are not described in this Notice.
You have the right to: a) inspect and copy your health information (generally EOBs),
with the exception of psychotherapy notes and/or information that requires a court
order; b) amend and restrict the health information that OSEEGIB discloses about you;
however, OSEEGIB is not required to agree to a requested restriction; c) request your
communications remain confidential with OSEEGIB; d) receive a copy of this Notice; e)
file a complaint if you believe OSEEGIB improperly used or disclosed your information;
f) request a listing of your protected health information disclosed by OSEEGIB except
that, as a health plan, OSEEGIB is not required to account for disclosures for claims
payment, OSEEGIB business operations, and disclosures you requested pursuant to your
written Authorization; and, g) receive a paper copy of this Notice upon request, if you
received this Notice electronically.
OSEEGIB reserves the right to change the terms of this Privacy Notice and will provide
all interested persons a revised notice either by U.S. Postal Service delivered to the
individual’s mailing address on file with OSEEGIB, or through electronic communication
by posting the revised Privacy Notice on the OSEEGIB website at www.sib.ok.gov and
www.healthchoiceok.com.
If you believe your privacy rights have been violated, call or send a written complaint to
the OSEEGIB HIPAA Information Officer at 3545 NW 58 Street, Suite 110, Oklahoma
City, OK 73112, 1-405-717-8701, toll-free 1-800-543-6044, TDD 1-405-949-2281, toll-free
TDD 1-866-447-0436; the Secretary of the U. S. Department of Health and Human
Services (HHS) at the Office of Civil Rights, 1301 Young Street, Suite 1169, Dallas,
TX 75202, 1-214-767-4056, or submit an electronic complaint according to directions
located on the HHS Office of Civil Rights website. Complaints to HHS must be filed
within 180 days after the date on which you became aware, or should have been aware,
of the violation. No retaliation is allowed against the individual filing a complaint.
Revised 2011
Information the Plan Must Provide to You
You have the right to get several kinds of information from HealthChoice. This Medicare
supplement handbook/Evidence of Coverage provides much of the information you need
59
Your Rights as a HealthChoice Member
concerning your health and pharmacy benefits, eligibility, premiums, and grievances and
appeals processes. It also provides information about the rules you must follow when you
use your prescription drug benefits, as well as why some drugs are not covered by the
Plan.
More information about the HealthChoice Pharmacy Network and coverage of specific
medications is available on our website at www.sib.ok.gov or www.healthchoiceok.com
or contact Medco, 24 hours a day, 7 days a week, at:
With Part D call toll-free 1-800-590-6828 or toll-free TDD 1-800-716-3231
Without Part D call toll-free 1-800-903-8113 or toll-free TDD 1-800-825-1230
Providing Information in a Way That Works For You
HealthChoice is required to provide information in a way that works for you. This
handbook/Evidence of Coverage is printed in a larger type to make it easier to read.
Additionally, a text version of this handbook is available on the HealthChoice website
at www.sib.ok.gov or www.healthchoiceok.com. This Medicare supplement handbook
is also available in CD format at the Oklahoma Library for the Blind and Physically
Handicapped (OLBPH). Contact OLBPH, Monday through Friday, 8:00 a.m. to 5:00 p.m.
with the exception of state holidays, at:
1-405-521-3514 or toll-free 1-800-523-0288
TDD users call 1-405-521-4672
If you are Medicare eligible because of a disability, HealthChoice is required to provide
you information about plan benefits that is accessible and appropriate for you. If you
have trouble getting information about your plan because of problems related to language
or disability, HealthChoice will work with you to provide plan materials in an appropriate
format. Please contact Member Services at:
With Part D call 1-405-717-8699 or toll-free 1-800-865-5142
Without Part D call 1-405-717-8780 or toll-free 1-800-752-9475
TDD users call 1-405-949-2281 or toll-free 1-866-447-0436
If HealthChoice does not respond appropriately to your request, you can file a complaint
with Medicare by calling toll-free 1-800-MEDICARE (1-800-633-4427), 24 hours a day,
7 days a week. TTY users call toll-free 1-877-486-2048.
Support for Your Right to Make Decisions About Your Care
Sometimes people become unable to make health care decision for themselves due to
60 Your Rights as a HealthChoice Member
accidents or serious illness. You have the right to give instructions about what is to be
done if you are not able to make medical decisions for yourself. This means, if you want
to, you can:
Fill out a written form to give someone the legal authority to make medical
decisions for you if you are unable to make decisions for yourself
Provide your doctors written instructions about how you want them to handle your
medical care if you become unable to make decisions for yourself
The legal documents you can use to give your instructions are called advance directives.
These documents are also called a living will or power of attorney for health care.
If you want to use an advance directive, here is what you do:
Get the form*
Fill it out and sign it
Give copies to the appropriate people
Take a copy with you if you are going to be hospitalized
You may also want to consult your attorney or ask them to help you prepare the
document.
*This form is free. For residents of Oklahoma, the form is available through a link
on the Oklahoma Attorney General's website at www.oag.state.ok.us/oagweb.nsf/
AdvanceDirective.
61
Your Rights as a HealthChoice Member
Grievances and Appeals
What to do if you have a complaint, a denied claim, or you disagree with a decision that
has been made about your health or pharmacy benefits. You cannot be disenrolled from
the Plan or penalized in any way for making a complaint, grievance, or appeal.
When Your Claim for Health Benefits is Denied (Plans with and
without Part D)
If your health claim is denied in whole or in part for any reason, you have the right to
have that claim reviewed. A request for review of your denied claim, along with any
additional information you wish to provide, must be submitted in writing to:
Medical Claims Review
P.O. Box 24870
Oklahoma City, OK 73124-0870
or call Monday through Friday, 7:30 a.m. to 6:00 p.m., Central time, at:
1-405-416-1800 or toll-free 1-800-782-5218
TDD users call 1-405-416-1525 or toll-free 1-800-941-2160
If your claim is reviewed and remains denied, you can appeal that decision to the
Grievance Panel. You can submit a request for a Grievance Panel hearing and represent
yourself in these proceedings. If you are unable to submit a request for a Grievance Panel
hearing yourself, only attorneys licensed to practice in Oklahoma are permitted to
submit your hearing request for you or to represent you through the hearing process [75
O.S. Section 310(5)].
All requests for hearings must be filed within one year of the date you are notified of the
denial of a claim, benefit, or coverage. All medical claim reviews and final decisions of
the Grievance Panel are made as quickly as possible. After exhausting claim review and
grievance procedures, an appeal can be pursued in Oklahoma District Court.
The Grievance Panel is an independent review group as established by statute 74 O.S.
Section 1306(6). For more information, contact:
The Legal Grievance Department
3545 NW 58 Street, Suite 110
Oklahoma City, OK 73112
1-405-717-8701 or toll-free 1-800-543-6044
TDD users call 1-405-949-2281 or toll-free 1-866-447-0436
62 Grievances and Appeals
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When Your Claim for Pharmacy Benefits is Denied —
Plans without Part D
We encourage you to contact us as soon as possible if you have questions, concerns, or
problems related to your prescription drug coverage. If your pharmacy claim is denied
and you have questions concerning the denial, please contact Medco, 24 hours a day, 7
days a week, at:
Toll-free 1-800-903-8113 or toll-free TDD 1-800-825-1230
If you want to appeal a denied pharmacy claim based on clinical criteria provided by your
physician, you can mail or fax your written appeal to:
OSEEGIB Pharmacy Unit
3545 NW 58 Street, Suite 110
Oklahoma City, OK 73112
Fax: 1-405-717-8925
If your appeal is denied, you have the right to file a grievance with OSEEGIB. Please
follow the same procedures used when appealing a denied health claim.
When Your Claim for Pharmacy Benefits is Denied —
Plans with Part D
The following is a summary of the guidelines for filing a Medicare Part D prescription
drug grievance or appeal. A complete Grievance and Appeals Guide for Pharmacy
Benefits is available on our website at www.sib.ok.gov or www.healthchoiceok.com or
by calling HealthChoice Member Services, Monday through Friday, 7:30 a.m. to 4:30
p.m., Central time, at:
1-405-717-8699 or toll-free 1-800-865-5142
TDD users call 1-405-949-2281 or toll-free 1-866-447-0436
Please let us know if you have questions, concerns, or problems related to your Part D
coverage. The contact information for each of the processes can be found in the Who to
Contact About Complaints, Appeals, Grievances, or Coverage Determinations section.
Making a Complaint – Filing a Grievance
The complaint/grievance process is used when you have problems related to the quality
of your care, waiting time, or the customer service you receive. A complaint/grievance
Grievances and Appeals
64
does not involve coverage or payment. The Medicare program sets rules about what
you need to do to make a complaint and what HealthChoice is required to do when a
complaint is received.
Complaints about the quality of care you receive under Medicare are handled by Medco,
HealthChoice, and/or by an independent organization known as the Quality Improvement
Organization (QIO).
There is a Quality Improvement Organization in each state. In Oklahoma, the organization
is called Health Integrity, LLC. Health Integrity has a group of doctors and other health
professionals who are paid by Medicare to check on and help improve the quality of care
for people with Medicare. Following are a few examples of quality of care issues:
You are unhappy about the quality of care you received, for example, you think
your pharmacist provided you with the wrong prescription or the wrong dosage.
You believe someone did not respect your privacy or was rude or disrespectful.
You believe a pharmacist or customer service representative kept you waiting too
long.
You think your hospital stay is ending too soon.
You think your home health care, skilled nursing facility care, or outpatient
rehabilitation care is ending too soon.
Following are some problems that might lead you to file a complaint/grievance:
You feel you are being encouraged to disenroll from HealthChoice.
You believe HealthChoice informational materials are difficult to understand.
HealthChoice doesn’t make a decision about your claim in the required time frame.
You disagree with a HealthChoice decision not to fast track your request for a
coverage determination or redetermination.
HealthChoice fails to forward your case to a certified Independent Review
Organization (IRO) when a decision is not made within the required time frame.
If you want to make a complaint about quality issues with the Part D prescription drug
program, you or your physician can contact Medco, 24 hours a day, 7 days a week, at:
Toll-free 1-800-590-6828 or toll-free TDD 1-800-716-3231
Coverage Decisions
Whenever you ask for coverage of a medication under Medicare Part D, it is called a
coverage decision. An example is when you take your prescription to be filled at the
pharmacy and coverage for your prescription is approved or denied.
Grievances and Appeals
If your request is denied, you can